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Patients with DLBCL on Medicaid had worse survival outcomes than those on commercial insurance, but there were no statistically significant differences in survival between races.
Data from a real-world database of patients with diffuse large B-cell lymphoma (DLBCL) show that among patients younger than 65 years, Medicaid use without access to commercial insurance was associated with worse overall survival (OS) than those who are commercially insured, though there was no significant difference in OS among patients of different races or ethnicities.1
Diffuse large B-cell lymphoma is the most common form of non-Hodgkin lymphoma. © David A Litman | stock.adobe.com
Published in Cancer Medicine, this study is one of the few that have evaluated socioeconomic disparities among patients with DLBCL through the proxies of race and ethnicity or insurance status. In this trial, these disparities are specifically linked with health outcomes for these patients.1
There is a documented higher mortality rate for Black patients compared with all other groups for many types of cancers. Additionally, non-Hispanic Black men have the highest rate of new cancer diagnoses. Based on these statistics and others, the investigators predicted that insurance status and race would indeed be linked to poorer outcomes in patients with DLBCL.1,2
The Flatiron Health database was utilized to retrieve data on patients. There were 5362 patients included in the study population; the group was 82.0% White, 7.3% Black, 7.9% Hispanic or Latino, and 2.7% Asian. Regarding insurance coverage, White patients were less likely to be enrolled in Medicaid, and they had the lowest Medicaid-to-commercial-insurance ratio at 0.05, compared with 0.16 for Black patients.1
Through a univariable analysis, variables statistically significantly associated with OS included sex, patient age at first-line treatment, disease state at initial diagnosis, site of care, and insurance status. However, a multivariable analysis based on the Cox model did not indicate a statistically significant difference in OS across various racial groups.1
Among Medicaid-insured patients aged less than 65 years old, significantly shorter OS was observed. Another multivariable analysis found no statistical significance among Medicaid-insured and commercially insured patients.1
1. Differences in insurance coverage served as predictors for survival in patients with diffuse large B-cell lymphoma.
2. Patients in different racial or ethnic groups did not have any statistically significant differences in survival outcomes.
3. Those who were younger than 65 years old and insured through Medicaid had worse outcomes than those who were 65 and older.
Time to second-line therapy or death to any cause (TTNTD) was not significantly different across racial groups, continuing this trend. Once again, there were no statistically significant differences in Medicaid-insured compared with commercially insured patients in TTNTD based on the Cox model.1
These findings contradict conclusions from earlier studies in the literature, which typically reported worse outcomes in Black patients with DLBCL compared with white patients. However, more recent data has shown similar outcomes between the two groups; a retrospective analysis by Flowers et al. suggests that the racial disparity seen in these earlier studies could be due to a change in treatment regimen that occurred in 2011.1,3
In January of that year, the predominant treatment method for patients with DLBCL changed from cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) to rituximab and CHOP (R-CHOP). In Flowers et al. analysis, they found that there were no racial differences found in the use of R-CHOP, while Black patients faced worse survival among those treated with CHOP.3
Interestingly, the difference in survival between insurance plans was not observed in patients aged 65 years or older. The investigators suggested that “broadening access to affordable health insurance at an early point in the diagnostic process could reduce the survival disadvantage for patients without adequate coverage.”1
Using data from the Flatiron Health database allowed the researchers to analyze comprehensive and thorough patient information with long follow-ups. However, the use of a database such as this comes with limitations, such as the missingness of some variables. Further, the number of Medicare patients in the study was relatively small compared to the number of commercial patients.1
“Future studies are needed to further evaluate the relationship between race/ethnicity and insurance status and the impact on survival outcomes in patients with DLBCL, and should consider social, environmental, biologic, and patient-related factors that contribute to potential disparities in DLBCL survival,” the investigators concluded.1
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