ASH 2021 Recap: Disparities in Care

Racial Disparities Are Seen in Survival Among Pediatric Patients With Acute Lymphoblastic Leukemia

White patients with acute lymphoblastic leukemia (ALL) had 5-year event-free survival (EFS) rates that were significantly higher than those seen among Hispanic and Black patients in a study of nearly 25,000 young people by the Children’s Oncology Group (COG). The findings were presented during 2021 American Society of Hematology Meeting & Exposition, held in Atlanta, Georgia, and online.

Of note for policy makers, US children with Medicaid coverage have lower survival rates than those not in Medicaid. But more surprising was the fact that children in the study living outside the United States—in countries such as Canada, Australia, or New Zealand—had event-free survival 29% higher than that of White children in the United States.

Sumit Gupta, MD, PhD, associate professor, Department of Pediatrics, The Hospital for Sick Children in Toronto, Canada, said that biological or genetic factors accounted for some of the gap in survival rates, but not all. “Our study shows that race- and ethnicity-based disparities continue to exist and are substantial,” Gupta said. “All groups do well overall, but some do substantially better than others.”

For the study, investigators examined a cohort of 24,979 children, adolescents, and young adults with ALL; about 92% were US residents. Patients who were non-Hispanic White accounted for 13,872 (65.6%) of the group, followed by 4354 (20.6%) who were Hispanic and 1517 who were non-Hispanic Black.

A little more than a quarter (27.8%; 6944 patients) were covered by US Medicaid.

The 5-year EFS was 87.4% (±0.3%) among non-Hispanic White patients vs 82.8% (±0.6%) for Hispanic patients (HR, 1.37; 95% CI, 1.25-1.49; P < .0001) and 81.9% (±1.2%) for non-Hispanic Black patients (HR, 1.45; 95% CI, 1.28-1.56; P < .0001). Investigators reported that outcomes for non-Hispanic Asian patients were similar to those of White patients.

Insurance status. US patients on Medicaid had worse outcomes compared with other US patients. Medicaid was associated with a 5-year EFS of 83.2% vs 86.3% for US patients not on Medicaid, (HR, 1.21; 95% CI, 1.12-1.30; P < .0001). Patients outside the US who were in this cohort had even better outcomes in 5-year EFS (89.0%; HR, 0.78; 95% CI, 0.71-0.88; P < .0001). However, this group was small relative to the overall group at 3151 patients.

Explanations for the findings. Gupta said the investigators sought to identify how these disparities could be explained by imbalances in other prognosticators. “For example, socioeconomic status did, unsurprisingly, vary by race ethnicity—50% of Hispanic patients were on Medicaid vs less than 20% of non-Hispanic White patients,” he said. “Similarly, disease prognosticators also vary by race and ethnicity.”

Investigators found that the worse outcome in EFS among Hispanic patients was substantially attenuated by the addition of disease prognosticators, with HR reduced from 1.37 to 1.17; this was further attenuated by including socioeconomic status (SES; HR, 1.11).

By contrast, investigators wrote, “the increased risk among non-Hispanic Black children (initially HR 1.45) was minimally attenuated by both the addition of disease prognosticators (to HR 1.38) and subsequent addition of SES (to HR 1.32).”

Notably, this process produced patterns in which “disparities in overall survival were wider than those seen in event-free survival,” Gupta said.

During the session, participants brought up possible confounders such as increased obesity rates or pulmonary arterial hypertension rates among Hispanic patients. Each of these may tell part of the story, and all are worth exploring.

“It is possible that there is residual confounding by disease prognosticators here that we did not fully account for,” Gupta said. “However, that seems unlikely to explain the full medical experience we’re seeing, so that we are then left with somewhat uncomfortable mechanisms to talk about such as differential access to care, differential quality of care.

“And when we use the unfortunately politically charged ‘systemic racism’ or another term, the possibility that even pediatric oncology health care systems are systematically delivering disparate care to patients across racial groups.”

B-ALL vs T-ALL. A key difference uncovered by this process is fact that disparities “restricted to children with B-ALL”, and not those whose leukemia is of T-cell lineage, Gupta noted, as he presented a slide showing the differences in the data.

During the press briefing, Gupta also stated, “The treatment [for both types of ALL] is pretty similar and delivered by the same centers.” Typically, a patient receives 8 to 10 months of intensive therapy followed by 18 to 24 months of lower-intensity or maintenance treatment. This second phase is where investigators may need to look for explanations for survival gaps, he said.

“There isn’t quite as much control and not quite as much monitoring that oncologists will do,” he said. “Maybe if, across these ethnic and racial groups, we’re delivering different care and maintenance, that might explain some of those findings.”

Reference

Gupta S, Teachey DT, Devidas M, et al. Racial, ethnic and socioeconomic factors result in disparities in outcome among children with acute lymphoblastic leukemia not fully attenuated by disease prognosticators: a Children’s Oncology Group study. Presented at: 63rd American Society of Hematology Meeting & Exposition; December 11-14, 2021; Atlanta, GA. Abstract 211. https://ash.confex.com/ash/2021/webprogram/Paper147386.html

Most Medicare Beneficiaries With CLL Diagnosis Don’t Get Therapy, Claims Analysis Finds

An analysis of Medicare claims by University of Maryland investigators found that just 16% of beneficiaries who have a diagnosis of chronic lymphocytic leukemia (CLL) ever receive treatment, and the likelihood of receiving therapy declines as patients reach advanced age or if they are female.

Investigators from the Department of Pharmaceutical Health Services Research and the Department of Medicine at the University of Maryland in College Park, along with investigators from BeiGene, examined these patterns through a claims study, which involved Medicare beneficiaries who received a diagnosis of CLL from 2017 to 2019. The results were presented in a poster during a session on health outcomes research at the 2021 American Society of Hematology Meeting & Exposition in Atlanta, Georgia.

According to the authors, 67% of patients with a new diagnosis of CLL are at least 65 years old. Thus, Medicare reimbursement policy has an outsize effect on access to care for the majority of the CLL patient population in the United States.

“While new agents and treatment combinations have been approved for CLL and treatment guidelines take into consideration age, frailty, and comorbidity status, limited information exists on current prescribing patterns or the demographic and clinical characteristics of individuals receiving them,” the study authors wrote.

Investigators used the Chronic Conditions Data Warehouse and identified Medicare beneficiaries with billing codes. Patients were included in the study if they (1) were 65 years or older and (2) were not treated for CLL during a continuous 6-month period when they were also enrolled in Medicare parts A, B, and D at baseline, with no evidence of enrollment in Medicare Advantage.

An index date was triggered by the date of first claim with a CLL diagnosis code during the cohort identification period, which ran from July 1, 2017, to June 30, 2019. Individuals were followed from the index date until they lost Medicare eligibility, until death, or until the end of the study, whichever came first. CLL treatments were evaluated based on whether they were included in the National Comprehensive Cancer Network guidelines; individuals were grouped by which treatment they received first.

CLL treatments included rituximab (Rituxan) monotherapy, ibrutinib (Imbruvica) monotherapy, bendamustine/rituximab (BR), obinutuzumab, and other treatment. Data points included share of patients who received first course of treatment, top-ranked regimens in the first course, median time to starting first course, and time in days from index date to initiation. The team created a visual representation of individual data points, adding demographic data, preventive health scores, and Charlson Comorbidity Index scores to see which factors made treatment more or less likely.

Results. The investigators reported a covariate-adjusted odds ratio (AOR), and an AOR less than 1 shows that “the comparison was negatively associated with the receipt of CLL treatment,” they said.

Investigators identified 3440 patients with CLL for evaluation; of these, just 16% (550) received CLL treatment, and the mean follow-up time was 540 days. Of the overall group, the mean age was 77 years; 49% were male.

Of the 556 treated patients, the first course of treatment was rituximab in 34%, BR in 12%, obinutuzumab in 4%, and other treatment in 14%. The mean (interquartile range) time to receipt of CLL treatment was 61 days; the median time to receipt of different therapies was as follows: ibrutinib, 109 days; rituximab, 49 days; BR, 53 days; and obinutuzumab, 140 days.

Less than half the patients in the BR group completed the recommended 6 doses. Compared with those in the rituximab group, a larger share of the ibrutinib and BR groups remained on their first treatment course.

The oldest patients (≥85 years) had an AOR of 0.69 (95% CI, 0.53-0.91) compared with those aged 65 to 74. Male patients had an AOR of 1.28 (95% CI, 1.06-1.54) compared with female patients. “No other statistically significant differences based on baseline measures were observed,” the investigators wrote.

“Among Medicare beneficiaries diagnosed with CLL, less than 2 out of 10 patients received CLL treatment,” they concluded. “The most common treatments administered during this time period were ibrutinib or rituximab. Younger age and male gender were factors associated with increased receipt of treatment.”

All study authors either receive research funding from BeiGene or are employed by BeiGene, the developer of zanubrutinib, which is being studied in patients with a new diagnosis of CLL. 

Reference

Onukwugha E, Lee TY, Abree J, et al. Factors associated with treatment among older adults diagnosed with chronic lymphocytic leukemia: an analysis using Medicare claims data. Presented at: 63rd American Society of Hematology Meeting & Exposition; December 11-14, 2021; Atlanta, GA. Abstract 1968. https://ash.confex.com/ash/2021/webprogram/Paper148727.html