Insurance Is No Longer a Determinant to Improve Overall Survival for Patients Diagnosed with HL, DLBCL or PCNS in an Enriched Hispanic Community
Authors: Velez-Mejia Carolina , Liu Qianqian , Michalek Joel E , Diaz Duque Adolfo Enrique 
Published: November 2021

Abstract
Background
Variables that determine overall survival (OS) in patients diagnosed with Hodgkin (HL) and Non-Hodgkin lymphomas (NHL) have been widely studied in the United States. Inequalities in survival has been noted when patients lack insurance (Cancer PMID: 26058564). However, healthcare disparities exist within the different cancer subtypes and ethnic minorities. In the case of Follicular lymphoma, uninsurance has been linked with worse outcomes (Blood PMC6137560). For Burkitt and plasmablastic lymphomas, insurance does not seem to have a repercussion in survival (Blood 136 Supplement 1:45-46) (Leuk Lymphoma PMC6923579). In subgroup analysis, Hispanics (HI) have been noted to have higher rate of uninsurance with no significant distinction in OS in patients with DLBCL (Blood136 Supplement 1: 9). There is a need to understand determinants in ethnic disparities in outcomes for HL and NHL. This is the first large statewide population-based study differentiating ethnicity, insurance status and survival for HL, diffuse large B cell lymphoma (DLBCL) and primary central nervous system lymphoma (PCNS) in Texas.
Material and Methods
A retrospective analysis of patients diagnosed with HL, DLBCL, PCNS recorded in the Texas Cancer Registry from 2006-2017 was carried out. Inclusion criteria was histopathologic proven HL, DLBCL, and PCNS. Patients were divided into HI and non-Hispanics (NH), and subsequently in insured (i) and uninsured (un), for a total of four cohorts for comparison: iHI, unHI, iNH and unNH. Survival time was measured using the day of diagnosis to last date of follow up or death. For each cohort, median survival (MS) and analysis at 2,5 and 10 years (y) was calculated. Survival distribution were determined based on Kaplan-Meier curves.
Results
From 2006-2017, 21,229 patients with HL, DLBCL, PCNS were diagnosed in Texas. Of these, 6,004 patients (iHI n=1,369, unHI n=376, iNH n=3,781, unNH n=478) were diagnosed with HL (Graph 1), 14,366 patients (iHI n=2,810, unHI n=635, iNH n=10,273, unNH n=648) were diagnosed with DLBCL (Graph 2) and 859 patients (iHI n=195, unHI n=54, iNH n=559, unNH n=51) were diagnosed with PCNS (Graph 3).
MS was outstanding for uninsured compared to insured patients with HL, DLBCL and PCSN. In HL, MS for iHI was 9.8 y, unHI was not reached, iNH was 10.3 y, and unNH was 10.8 y. In DLBC, MS was 3.7 y, 9.3 y, 4.2 y and 5.3 y, respectively. In PCNS, MS for these groups corresponded to 0.9 y, 0.8 y, 0.7 y and 3.2 y.
Survival probability at 2-,5- and 10y among i vs un was noteworthy in HL, DLBCL and PCNS (Table 1). In HL, iHI was 0.762, 0.686 and 0.448; unHI was 0.873, 0.784 and N/A; iNH was 0.843, 0.765 and 0.584, and unNH was 0.846, 0.782 and 0.703, respectively. In DLBCL, for iHI it was 0.573, 0.456 and 0.222; unHI was 0.685, 0.631 and 0.350; iNH was 0.602, 0.469 and 0.174; unNH was 0.583, 0.510 and 0.239, accordingly. In PCNS, for iHI it was 0.374, 0.219 and N/A; unHI was 0.314, 0.174 and N/A; iNH was 0.354, 0.229 and 0.061; unNH was 0.516, 0.473 and 0.473, correspondingly.
Overall Survival (OS) was statistically significant for iHI vs unHI vs iNH vs unNH when comparing HL, DLBCL and PCNS, with p values of &lt;0.0001, &lt;0.0001 and 0.037, respectively (Graph1-3). In HL the group with the best OS was unHI. This was also evidenced for DLBCL. However, for PCNS this trend was noted in unNH. In both three malignancies, the highest OS rate was reported in uninsured population.
Conclusions
For HL, DLBCL and PCNS the uninsured population has statistically significant better OS at 10 y. Interestingly for HL and DLBCL this corresponded to unHI while for PCNS was unNH. This paroxysmal finding may be due to standardized treatment, immediate healthcare enrolling after diagnosis and/or different community healthcare practices. Additionally, this population may have unique behaviors such as higher rate of compliance/adherence, environmental exposures or genetic predisposition to improved survival. Nonetheless, lack of insurance may delay diagnosis, need for multiple lines of chemotherapies, increase the rate of metastatic disease or recurrences. Accordingly, as more expensive and personalized therapies evolve, insurance status can limit access to these treatment regimens. Therefore, although insurance is no longer a determinant for improving OS for patients diagnosed with HL, DLBCL or PCNS, it can have implications for other oncological outcomes.
Figure 1 Figure 1.

Disclosures
Diaz Duque: Incyte: Consultancy; Morphosys: Speakers Bureau; Astra Zeneca: Research Funding; Hutchinson Pharmaceuticals: Research Funding; Epizyme: Consultancy; ADCT: Consultancy.