AYAs with rare leukemia face disparities in access to specialized cancer centers
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Key takeaways:
- Age, race/ethnicity and insurance influenced odds of care at a specialized center for adolescents and young adults with ALL.
- Treatment at specialized centers correlated with longer survival for these patients.
CHICAGO — Fewer than half of adolescents and young adults with acute lymphoblastic leukemia received first-line treatment at a specialized cancer center, despite an association of such treatment with longer survival, study results showed.
The findings, presented at ASCO Annual Meeting, also revealed independent associations of age, race/ethnicity and insurance type with odds of treatment at a specialized center.
“These results suggest there are disparities in access to centers with specialization in ALL,” Lori S. Muffly, MD, MS, of the division of blood and marrow transplantation and cellular therapy at Stanford University School of Medicine, told Healio.
Background, methodology
ALL is a difficult cancer to treat due to its rarity and complex therapeutic algorithms, Muffly said.
Children with ALL typically receive care at specialized NCI- and Children’s Oncology Group-designated cancer centers, but care for adolescents and young adults (AYAs) with ALL can occur in a variety of settings.
Muffly and colleagues used data from 2004 to 2018 state cancer registries in California, New York and Texas to identify where AYAs —defined as individuals aged 15 to 39 years — diagnosed with ALL received front-line treatment and whether associations existed between initial treatment at a specialized cancer center and leukemia-specific survival (LSS) and OS.
The cohort included 2,283 AYAs with ALL from California, 955 from Texas and 795 from New York. Most were aged 18 years or older (70%) and male (65%). Researchers noted variations in race/ethnicity, with higher proportions of Hispanic patients in California (63%) and Texas (64%) compared with New York, where half of patients were non-Hispanic white. Most in New York (54%) had private health insurance coverage, whereas 48% in California had public insurance. Texas had the highest uninsured rate, at 18%.
Results
California had the highest rate of treatment at a specialized cancer center (48.2%), followed by New York (44.4%) and Texas (19.5%). Rates increased in California and New York over time but did not change in Texas.
Adjusted models showed associations between older age and lack of insurance with lower odds of treatment at a specialized cancer center. In addition, researchers reported significantly lower odds of ALL care at a specialized center for Hispanic vs. non-Hispanic white patients in California (OR = 0.58; 95% CI, 0.45-.074) and Texas (OR = 0.55; 95% CI, 0.35-0.86) and for those with public vs. private insurance in New York (OR = 0.45; 95% CI, 0.31-0.67) and Texas (OR = 0.49; 95% CI, 0.3-0.8).
Further analysis showed significant associations of front-line treatment at a specialized cancer center with superior survival outcomes in California (LSS and OS, HR = 0.73; 95% CI, 0.63-0.85) and Texas (LSS, HR = 0.7; 95% CI, 0.51-0.94; OS, HR = 0.61; 95% CI, 0.45-0.83) and a nonsignificant association in New York (LSS, HR = 0.86, 95% CI 0.65-1.12; OS, HR = 0.83, 95% CI 0.64-1.08).
Implications, next steps
The findings highlight the need for state and federal policies to reduce disparities in specialized care for AYAs with ALL, according to Muffly.
“I take our study results to imply that we should be addressing access to specialized cancer care at the public policy level, particularly for disadvantaged patients,” she told Healio.
The California Cancer Care Equity Act, which took effect Jan. 1, is a first step toward improving access in that state, Muffly said. The act provides patients with complex cancer who have Medicaid the opportunity to receive care at specialized cancer centers.
“However ... because of vastly different policies, economics and access among states, a one-size-fits-all approach will likely be insufficient,” she said. “Advocacy groups and state legislatures will need to promote strategies that may advance specialty cancer care access differently in each state.”
In addition, insurers and institutions should reconsider their approach to coverage at specialized centers for AYAs with ALL, according to Muffly.
“Further, nontraditional specialized cancer centers that exist outside of the typical NCI-CC/academic framework and often have vast leukemia expertise should be better studied and evaluated as a possible model to extend specialized cancer center-level care throughout the community,” she said.
Future research from her group, supported by an award from the Leukemia and Lymphoma Society, will include examining the role of specific types of insurance coverage on access to specialized ALL care, barriers at the institutional level and the economic impact of transitioning more patients to specialized cancer centers.
“We hope our work will help establish this issue as one of importance in the acute leukemia research and clinical community,” she said.
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Muffly L, et al. Abstract 7008. Presented at: ASCO Annual Meeting; June 2-6, 2023; Chicago.
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