‘Insuring’ better outcomes
In the last couple months, I have seen two young patients in my lymphoma clinic for whom insurance issues have had a significant effect on their care.
The first was a well-insured young man with a new diagnosis of classical Hodgkin lymphoma in a neck node. I saw him for his first oncology consultation. He likely had early-stage disease, and we set up a standard diagnostic and staging evaluation.
At the end of the consult, the patient explained that our institution is out of network for him (ironically, he works for that company). The patient tried unsuccessfully to appeal his insurance company’s decision that he should receive his care in network.
The second patient was a young woman with a bulky abdominal mass who presented through a local ED with severe abdominal and back pain. The mass was diagnosed as diffuse large B-cell lymphoma, and she was referred to our clinic for further evaluation and treatment.
It turns out this patient was uninsured but has significant — although not unlimited — financial resources. With the help of our financial counselors, we have been able to initiate her therapy with some constraints on expensive supportive drugs.
Both these patients have, fortunately, had good outcomes so far.
The young man is being treated at another clinic, is doing well and has a high probability for cure. The young woman is tolerating therapy well and has had an excellent response so far.
Still, both these stories are illustrative of the fact that insurance challenges compromise best care.
In both cases, trying to navigate the financial issues resulted in delays in workup and treatment and, undoubtedly, in additional stress and anxiety for the patients and their families. Whether these delays ultimately will affect the outcomes for these two patients is unclear, although it is unlikely, as both have highly treatable diseases with high cure rates.
Evidence from previous studies has shown that patients with Hodgkin lymphoma or DLBCL who are uninsured or rely on Medicare or Medicaid coverage are less fortunate than these two patients. They have been shown to have inferior OS compared with those who have private insurance.
These disparities in survival appear to persist even after controlling for socioeconomic factors and, in part, appear to be related to delayed diagnosis, more advanced stage at diagnosis, and higher incidence of comorbidities in the uninsured and publicly insured patient groups.
Access to the most effective therapies also may be a factor; however, because many of these studies have been based on large databases, such as the National Cancer Database (NCDB), detailed information on therapy is lacking.
Whatever the precise reasons for this poorer survival, there is little doubt that access to affordable health care is likely to lessen this disparity, understanding that other socioeconomic and health literacy factors mean it is unlikely that the playing field will be completely leveled.
The example of follicular lymphoma
Although the evidence for such disparities has been demonstrated quite clearly for hematologic malignancies for which therapy is, to some extent, episodic, data for more indolent diseases has been lacking.
A study from researchers at Emory University, The University of Texas MD Anderson Cancer Center and American Cancer Society suggests that similar disparities in outcome — based on insurance status — exist for patients with follicular lymphoma (see page 35).
Follicular lymphomas are characterized mostly by a very indolent clinical course and a tendency to respond well to multiple lines of therapy. Although regarded as incurable, therapeutic advances over the last 15 years have extended the median survival for patients with follicular lymphoma substantially.
Many of these patients eventually will receive several lines of treatment.
In fact, as the prognosis for patients with follicular lymphoma has improved and more effective therapies have emerged, it has become increasingly challenging to design clinical trials with an OS endpoint.
Effective second or subsequent therapies have changed the paradigm for treatment of follicular lymphoma into one of chronic disease management rather than sequential episodic care.
Despite these advances, this recent study — conducted among patients diagnosed between 2004 and 2014 — shows that insurance status is a predictor of survival in follicular lymphoma.
Like several other studies, this one used data from the NCDB and, therefore, has some significant flaws, particularly with respect to treatment details. Despite this, given the very large number of patients included in the study, the results can’t be ignored.
The major, high-level conclusions from the study are concerning.
First, among the entire patient population of all age groups, those with no insurance, Medicaid or Medicare had shorter OS than those with private insurance.
Second, among those aged 65 years and older, patients with Medicare only had inferior survival to those who were privately insured. Except in the elderly cohort, patients with no insurance, Medicare or Medicaid were more likely to have a delay in therapy, but more likely to receive systemic therapy, presumably reflecting the advanced nature of their disease at presentation.
Although these patients were more likely to receive systemic therapy, previous studies have shown that patients who do not have private insurance are less likely to receive chemoimmunotherapy regimens, now standard of care for frontline therapy of follicular lymphoma. As the authors of this study point out, if this contributes to the disparity in survival, it is likely to get worse in the future as more expensive but active agents are introduced.
Prevalence of financial hardship
As access to health care improves through the effects of the Affordable Care Act, it’s important to remember that, at least for patients with follicular lymphoma, many other factors play into the disparities uncovered in this study — the fact that patients with Medicaid and Medicare are apparently still disadvantaged in survival terms underlines the complexity of this problem. That said, there are already emerging data in other cancers that have shown that improved coverage has led to earlier diagnosis.
It’s also important to remember that having private insurance certainly doesn’t insulate cancer patients from substantial financial hardship.
The financial toxicity of cancer treatment has been discussed extensively.
In a newly published study from Duke and Massachusetts General Hospital, investigators surveyed privately insured patients with advanced solid cancers to assess the level of their financial sacrifices and their willingness to face financial hardship.
A high proportion of patients were willing to sell their homes, declare bankruptcy or borrow money to meet the costs of their care. Patients were more inclined to use their savings over time to meet the costs of care.
If insured patients — who have resources — are facing significant and increasing financial hardship to meet the costs of their care, it’s not surprising that the uninsured or those with Medicaid or Medicare are likely to be at higher risk for a poor outcome.
Better access to affordable care clearly is only part of the solution but, as the study in follicular lymphoma shows, it’s one step toward reducing an unacceptable disparity in outcome.
Chino F, et al. J Oncol Pract. 2018;doi:10.1200/JOP.18.00112.
Goldstein JS, et al. Blood. 2018;doi:10.1182/blood-2018-03-839035.
Han X, et al. Cancer. 2014;doi:10.1002/cncr.28549.
For more information:
John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director of Huntsman Cancer Institute at The University of Utah. He can be reached at firstname.lastname@example.org.
Disclosure: Sweetenham reports no relevant financial disclosures.