Impact of Treatment and Insurance on Socioeconomic Disparities in Survival after Adolescent and Young Adult Hodgkin Lymphoma: A Population-Based Study

Abstract

Background Previous studies documented racial/ethnic and socioeconomic disparities in survival after Hodgkin lymphoma (HL) among adolescents and young adults (AYAs), but did not consider the influence of combined-modality treatment and health insurance. Methods Data for 9,353 AYA patients aged 15–39 when diagnosed with HL during 1988–2011 were obtained from the California Cancer Registry. Using multivariate Cox proportional hazards regression, we examined the impact of socio-demographic characteristics (race/ethnicity, neighborhood socioeconomic status (SES), and health insurance), initial combined-modality treatment, and subsequent cancers on survival. Results Over the 24-year study period, we observed improvements in HL-specific survival by diagnostic period and differences in survival by race/ethnicity, neighborhood SES and health insurance for a subset of more recently diagnosed patients (2001–2011). In multivariable analyses, HL-specific survival was worse for Blacks than Whites with early-stage (Hazard Ratio (HR): 1.68; 95% Confidence Interval (CI): 1.14, 2.49) and late-stage disease (HR: 1.68; 95% CI: 1.17, 2.41) and for Hispanics than Whites with late-stage disease (HR: 1.58; 95% CI: 1.22, 2.04). AYAs diagnosed with early-stage disease experienced worse survival if they also resided in lower SES neighborhoods (HR: 2.06; 95% CI: 1.59, 2.68). Furthermore, more recently diagnosed AYAs with public health insurance or who were uninsured experienced worse HL-specific survival (HR: 2.08; 95% CI: 1.52, 2.84). Conclusion Our findings identify several subgroups of HL patients at higher risk for HL mortality. Impact Identifying and reducing barriers to recommended treatment and surveillance in these AYAs at much higher risk of mortality is essential to ameliorating these survival disparities.

Sociodemographic disparities in survival for adolescents and young adults with cancer differ by health insurance status

“…marital status, race/ethnicity, and neighborhood SES) are considered and is apparent for each of the eleven most common AYA cancers. Given that the small percentage of AYA cancer patients who were uninsured likely reflect retroactive enrollment in Medicaid at the time of cancer diagnosis [8, 13, 14], we considered publicly insured and uninsured together in the survival analyses. A number of factors related to healthcare access may mediate associations of no or public insurance with survival; including stage at diagnosis, delays in treatment receipt, details of treatment receipt and completion, Medicaid provider restrictions, or availability of information and support services among patients and survivors.…”

“…As in previous AYA studies [11, 13, 24, 25], insurance type was categorized as private/military (private insurance managed care, health maintenance organization, or preferred provider organization; private Insurance Fee-for-Service; military; Veterans Affairs; Tricare; or insurance, not otherwise specified), public/none (Medicaid, Medicare, Indian/Public Health Service, county funded not otherwise specified, not insured, not insured self-pay), and unknown. Consistent with prior observations that the small percentage of AYA cancer patients who were uninsured likely reflect retroactive enrollment in Medicaid at the time of cancer diagnosis [8, 13, 14], we considered publicly insured and uninsured together in the survival analyses.…”

“…It is well-documented that, compared to non-Hispanic White AYAs, Hispanic and Black AYAs are more likely to reside in lower SES neighborhoods [10] and are more likely to be uninsured or have public insurance [11, 12]. Furthermore, each of these sociodemographic factors (i.e., minority race/ethnicity, lower neighborhood SES, and public or no insurance at diagnosis) have been associated with later-stage at diagnosis [11–13], undertreatment [7, 11], and greater risk of death among AYAs [7–11, 13, 14]. The few studies that have considered the independent associations of all three factors with cancer survival suggest that these associations remain in multivariable analyses, but differences exist by cancer site [8–10, 14].…”

“…Furthermore, each of these sociodemographic factors (i.e., minority race/ethnicity, lower neighborhood SES, and public or no insurance at diagnosis) have been associated with later-stage at diagnosis [11–13], undertreatment [7, 11], and greater risk of death among AYAs [7–11, 13, 14]. The few studies that have considered the independent associations of all three factors with cancer survival suggest that these associations remain in multivariable analyses, but differences exist by cancer site [8–10, 14]. Of note, however, no studies have considered the joint relationship of race/ethnicity, neighborhood SES, and health insurance type with survival among AYAs.…”

Adolescent and Young Adult Oncology, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology

“…222 An analysis of 9,353 AYA patients with HL showed that having either public or no health insurance was associated with poorer HL-specific survival compared with patients with private or military insurance (HR, 2.08; 95% CI, 1.52-2.84). 223 Furthermore, unemployment and lack of health insurance appear to be significant predictors of psychological distress in the childhood cancer survivor population. 224 Uninsured AYA patients are also less likely to participate in clinical trials.…”