Treatment Disparities Faced by Undocumented Workers From Low- and Middle-Income Countries in the United States With Hematologic Malignancies
Authors: Sara E. Nunnery, Andrew E. Fintel, W. Clay Jackson, Jason C. Chandler, Michael O. Ugwueke, Mike G. Martin
Journal: Journal of the National Comprehensive Cancer Network (2016)

Acute and chronic leukemias are potentially curable with systemic chemotherapy and hematopoietic stem cell transplantation (HSCT), but they present a challenge within oncology due to the intense amount of supportive care required during treatment.Furthermore, the millions of undocumented immigrants currently living in the United States have extremely limited access to life-saving treatments if diagnosed with a catastrophic illness such as a hematologic malignancy.The inadequate access to cancer care in the United States faced by these immigrants is a growing issue that needs to be confronted by the medical community. Cancer Care for Immigrants in the United StatesCensus data from 2011 suggest that more than 18 million foreign-born Hispanic immigrants living in the United States have emigrated from low-and middle-income countries (LMICs).Approximately 13 million immigrants are noncitizens of Mexican origin, and only 25% are lawfully present. 1 Undocumented immigrants currently have limited access to health care in the United States.A study by Bustamante et al 2 found that undocumented Mexican immigrants are significantly less likely to have had a physician visit in the previous year or have a regular source of health care compared with documented Mexican immigrants.Under the 2010 Patient Protection and Affordable Care Act, immigrants with documentation can purchase health insurance through exchanges, and low-income immigrants with documentation can be eligible for Medicaid after a 5-year waiting period.However, undocumented immigrants are still excluded from being able to purchase health insurance in the exchanges and from becoming eligible for Medicaid. 3nless they can find physicians and facilities willing to provide pro bono treatment, undocumented immigrants diagnosed with catastrophic illnesses such as hematologic malignancies or other cancers have no options for receiving potentially life-saving treatments with chemotherapy, targeted therapies, and HSCTs.We have faced these treatment challenges with undocumented immigrants who presented to our institution with acute and chronic leukemias.For example, a 21-year-old Hispanic man presented to our hospital with a WBC count of 103,000 cells/mcL with 94% blasts.After he underwent urgent leukapheresis, a bone marrow biopsy was performed and a diagnosis of acute myeloid leukemia (AML) was made.He was started on induction chemotherapy with cytarabine, idarubicin, and cladribine (7+3+5). 4The final bone marrow biopsy revealed high-risk AML with an MLL rearrangement (45, X, -Y, t(10;11)(p11.2;q23))and an isolated FLT3-ITD.His day 14 bone marrow biopsy showed a prominent blast population consistent with his initial biopsy, so he received salvage chemotherapy with cladribine, cytarabine, and mitoxantrone (CLAM). 5Repeat bone marrow biopsies on days 7 and 30 after CLAM showed a complete remission.He had originally come to the United States from Mexico on a work visa to pick apples, but his visa had expired before his presentation.Given his high-risk AML status, we felt an allogeneic stem cell transplant provided the best chance of cure.However, he would not be able to receive a transplant and the long-