Increased Rates of Allogeneic Hematopoietic Stem Cell Transplantation and Overall Survival in Philadelphia-Positive Acute Lymphoblastic Leukemia Patients with Broader Health Insurance Coverage

Abstract

Introduction The Philadelphia chromosome is associated with a poor prognosis in patients with acute lymphoblastic leukemia (ALL). While modern day therapies including allogeneic hematopoietic stem cell transplantation (HSCT) have led to significant improvements in overall survival (OS) for this population, these treatments have variable accessibility in patients with limited to no health insurance. Methods We performed a single-center, retrospective study to investigate outcomes in Ph+ ALL adults with different types of health insurance. Health insurance options included Medicare, private insurance, Medicaid, or no insurance. Allogeneic HSCT was performed in patients who met transplant eligibility criteria of insurance coverage and caregiver availability at home. Patient OS was defined as the time from diagnosis of Ph+ ALL until patient death. Statistical analysis was performed using the Fisher's exact probability test with two-tailed p-values Results A total of 81 patients with Ph+ ALL were included in this study. Two groups of patients were compared: those with either Medicare or private insurance (M/P) versus those with Medicaid or no insurance (M/N). Thirty-three patients (40.7%) were included in the M/P group and 48 patients (59.2%) in the M/N group. Twenty patients (60.6%) in the M/P group were able to undergo allogeneic HSCT in contrast to 15 patients (31.3%) in the M/N group (p = 0.012). There were similar rates of caregiver availability to support HSCT between both groups; 24 M/P patients (72.7%) lived with a caregiver versus 33 M/N patients (68.8%) in comparison (p = 0.806). In analyzing rates of OS, the 1-year OS was 100% vs. 85.1% (p = 0.038), 2-year OS was 96.2% vs. 75.8% (p = 0.033), and 3-year OS was 88.2% vs. 59.2% (p = 0.049) for M/P patients compared to M/N patients, respectively. Conclusion With the emergence of allogeneic HSCT, the rates of OS in the Ph+ ALL population improved dramatically from the prior era. However, barriers still exist to undergoing transplant, one of the most formidable being appropriate insurance coverage. This study demonstrated that a significantly higher percentage of Ph+ ALL patients in the M/P group were able to undergo allogeneic HSCT compared to those in the M/N group. While eligibility for transplant depended on caregiver availability in addition to insurance status, there were similar rates of caregivers between the two groups, thus implying that this factor had no major impact on the differing rates of HSCT. Furthermore, M/P patients were found to have significantly higher rates of OS at the 1-year, 2-year, and 3-year marks compared to those in the M/N group. Given that broader health insurance coverage was correlated with increased rates of both allogeneic HSCT and OS, it remains a critical point of discussion in the treatment of Ph+ ALL patients from all socioeconomic backgrounds.