Insurance disparities put patients with AML subtype at significant survival disadvantageMay 10, 2021
Jamy reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Pemmaraju reports consultant roles with/honoraria from AbbVie, Blueprint Medicines, Bristol Myers Squibb, Celgene, DAVA Oncology, ImmunoGen, Incyte, LFB Biotechnologies, Mustang Bio, Novartis, Pacylex Pharmaceuticals, Roche Diagnostics, Sanofi, Springer Science + Business Media LLC and Stemline Therapeutics, as well as other relationships with several pharmaceutical companies.
Patients with acute promyelocytic leukemia who lack health insurance demonstrated a significant survival disadvantage compared with their insured counterparts, according to results of a study published in Cancer.
Researchers observed a similar disadvantage among Medicaid recipients aged 40 years or older with acute promyelocytic leukemia (APL) vs. those in the same age group who had other insurance.
“Our findings highlight the disparate outcomes in both young and old patients diagnosed with APL based on insurance status,” Omer H. Jamy, MD, assistant professor in the division of hematology and oncology of the department of medicine at The University of Alabama at Birmingham, told Healio.
Survival among patients with APL, which accounts for about 5% to 20% of all acute myeloid leukemia diagnoses in the U.S., has improved markedly with the use of all-trans retinoic acid and arsenic trioxide, with updated clinical trial results showing 4-year rates of 96% for EFS and 99% for OS, according to study background. However, Jamy said, it remained unclear whether those results translated to the general population.
Omer H. Jamy
“The need for immediate diagnosis, access to specialized care and the complexity and cost of APL management may potentially act as a barrier for disadvantaged patients,” Jamy said. “In this context, we hypothesized that sociodemographic factors, particularly insurance status, could affect the outcomes of patients diagnosed with APL and tested it utilizing a large population-based data set.”
Researchers used data from the SEER database to analyze 1,787 patients with APL diagnosed between 2007 and 2015 (median age at diagnosis, 41 years; range, 0-64; 52.5% male, 52.3% non-Hispanic white). Among the 971 patients aged 40 years and older, 749 (77%) had insurance, 171 (18%) had Medicaid and 51 (5%) had no insurance. Among the 816 patients aged younger than 40 years, 522 (64%) had insurance, 244 (30%) had Medicaid and 50 (6%) had no insurance.
Results among those aged younger than 40 years showed higher mortality rates for uninsured patients at 1 month and 2 months (30% for both) compared with insured patients (8.6% at 1 month, 10.8% at 2 months) and Medicaid recipients (9% at 1 month, 9.2% at 2 months). Researchers reported higher 5-year OS rates for insured patients (86.2%) and Medicaid recipients (84.9%) than uninsured patients (70%) in this group. Patients without insurance had worse outcomes than patients with insurance (P < .001) and Medicaid recipients (P = .004).
Multivariable analysis showed associations of a higher risk for death among the younger group with being uninsured (vs. insured, HR = 2.33; 95% CI, 1.32-4.1), as well as improved survival among women vs. men (HR = 0.52; 95% CI, 0.35-0.76) and with each year of diagnosis (HR per additional year = 0.88; 95% CI, 0.8-0.95).
Among patients aged 40 years and older, those without insurance had higher mortality rates than Medicaid recipients and those with insurance at 1 month (41.2% vs. 22.8% vs. 18.4%) and 2 months (52.9% vs. 28.7% vs. 19.8%).
Researchers characterized 5-year OS among this group as significantly associated with insurance status at diagnosis, with rates of 73.5% for insured patients, 63% for Medicaid beneficiaries and 43.6% for the uninsured. Patients without insurance had worse outcomes than patients with insurance (P < .001) and Medicaid recipients (P = .015).
Multivariable analysis among the older group showed associations of a higher risk for death with being uninsured (vs. insured, HR = 2.54; 95% CI, 1.68-3.83), being a Medicaid recipient (vs. insured, HR = 1.52; 95% CI, 1.13-2.03) and with increasing age (HR per additional year = 1.04; 95% CI, 1.02-1.06).
Jamy called on further research to bring such disparities to light and improve access to care for all.
“Given the recent emphasis on comparative effectiveness in oncology, it is important to account for sociodemographic variables when comparing health care systems and therapeutic approaches,” he told Healio. “In addition to understanding the underlying biology of disease to come up with effective treatment options, addressing sociodemographic barriers to care also provides an opportunity to improve outcomes in the general population.”
In an accompanying editorial, Naveen Pemmaraju, MD, associate professor in the department of leukemia of the division of cancer medicine at The University of Texas MD Anderson Cancer Center, wrote that the study by Jamy and colleagues raises the fundamental question of whether management of APL can be improved.
“The answer is, of course, yes,” Pemmaraju wrote. “Patients with life-threatening blood cancers such as APL must have access to higher level medical care, access to major medical centers and access to expertise, regardless of insurance status or ability to pay. We must come together as a medical community to join forces to make sure that all patients may be treated equally and fairly, regardless of financial station, disease rarity or disease complexity, and have the right and opportunity to seek cures for even the rarest of diseases.”
Jamy OH, et al. Cancer. 2021;doi:10.1002/cncr.33593.
Pemmaraju N. Cancer. 2021;doi:10.1002/cncr.33594.
For more information:
Omer H. Jamy, MD, can be reached at Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, 1720 2nd Ave. South, NP2540W, Birmingham, AL 35294; email: firstname.lastname@example.org.