Impact of Insurance Status on Survival Outcomes in Adults with Acute Lymphoblastic Leukemia (ALL): A Single Center Experience
Authors: Krakora Rebecca , Shih Weichung , Popli Pallvi , Gorshein Elan , Salaru Gratian , David Kevin A. , Bannerji Rajat 
Published: November 2019

INTRODUCTION
Five year survival for adults diagnosed with Acute Lymphoblastic Leukemia (ALL) is approximately 30-40% and decreases with older age at diagnosis. Although survival rates have improved over the last few decades, identifying risk factors for worse survival remains critical to improving outcomes. Previous studies in Acute Myeloblastic Leukemia (AML) and ALL have demonstrated disparities in survival rates based on race, ethnicity and poverty level. Lack of health insurance may also negatively impact survival in acute leukemias by impeding access to therapy and delaying treatment initiation. These issues are particularly problematic for hematologic malignancies where the costs of multidrug chemotherapy, prophylactic drugs and allogeneic stem cell transplant (ASCT) are significant. Our study investigates survival outcomes in uninsured vs. insured adult patients with ALL at a single comprehensive cancer center.
METHODS
This study was an IRB-approved retrospective chart review of patients diagnosed with B-lineage ALL between January 1, 2007 and October 31, 2017 and treated on the adult leukemia service at our institution. Charts were reviewed for demographic, diagnostic, cytogenetic and molecular data, as well as treatment history and response. A total of 136 patients were included and follow up extended through January 19, 2018. Insurance status was determined at time of diagnosis and defined as any insurance (including public) versus no insurance. Differences between the two groups were assessed using chi-square tests. Cox proportional hazard regression methods were used for univariate and multivariate analyses for overall survival (OS) and progression-free survival (PFS).
RESULTS
A total of 136 patients were included, 29 without insurance at time of diagnosis and 107 with insurance. Of the patients without insurance, 6.9% were ≥60 years old at time of diagnosis compared to 45.8% of the patients with insurance (p=0.0001). Patients without insurance were also more likely to be Hispanic or Latino compared to patients with insurance (72.4% vs 10.3%, p= <0.0001). There was no statistically significant difference in baseline white count (≥30,000 or <30,000 x 109/L), Philadelphia chromosome status, receipt of ASCT or achievement of complete remission (CR) between the 2 groups. In univariate analyses, insurance status was not associated with OS or PFS. Only achievement of CR was associated with better OS and PFS. In multivariate analyses, achievement of CR and Hispanic or Latino ethnicity were associated with better OS and PFS. However, insurance status also became a statistically significant factor associated with better PFS.
CONCLUSIONS
In this study, we found no significant difference in OS between ALL patients based on insurance status. However, when controlling for other variables, lack of health insurance was associated with worse PFS. These results suggest that uninsured patients may be at a disadvantage in terms of their leukemia outcomes. Patients with health insurance may have fewer obstacles to timely, effective therapy, which decreases their chance of relapse. Our finding that Hispanic or Latino patients had better OS and PFS was surprising and may be explained by the generally younger age of these patients in our population. Further research is needed to investigate how lack of insurance specifically affects leukemia management and patient outcomes.

Disclosures
Bannerji: Regeneron Pharmaceuticals, Inc.: Consultancy, Other: travel support, Research Funding; AbbVie, Inc: Consultancy, travel support; Celgene: Consultancy; Pharmacyclics: Other: travel support; Pharmacyclics: Other: travel support; Gilead: Other: travel support; Gilead: Other: travel support; AbbVie, Inc: Consultancy; Merck: Other: travel support, Patents & Royalties: IP rights; Regeneron Pharmaceuticals, Inc.: Consultancy, Other: travel support, Research Funding; Celgene: Consultancy; Merck: Other: travel support, Patents & Royalties: IP rights.