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Karmali R, Machhi R, Epperla N, Shouse G, Romancik J, Moyo TK, Kenkre V, Ollila TA, Fitzgerald L, Hess B, David K, Roy I, Zurko J, Chowdhury SM, Annunzio K, Ferdman R, Bhansali RS, Harris EI, Liu J, Nizamuddin I, Ma S, Moreira J, Winter J, Pro B, Stephens DM, Danilov A, Shah NN, Cohen JB, Barta SK, Torka P, Gordon LI. Impact of race and social determinants of health on outcomes in patients with aggressive B-cell NHL treated with CAR-T therapy. Blood Adv 2024; 8:2592-2599. [PMID: 38531057 DOI: 10.1182/bloodadvances.2023011996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/05/2024] [Accepted: 02/26/2024] [Indexed: 03/28/2024] Open
Abstract
ABSTRACT Chimeric antigen receptor (CAR) T-cell (CAR-T) immunotherapy is an effective therapy for relapsed/refractory B-cell non-Hodgkin lymphoma (r/r B-NHL). However, data are limited on the impact of the convergence of race and social determinants of health on outcomes for patients treated with CAR-T therapy. We examined the impact of interactions between race and insurance type on health care use and outcomes in patients treated with CAR-T therapy for aggressive B-NHL. Adult patients with r/r B-NHL treated with CD19 CAR-Ts were identified between 2015 and 2021 across 13 US academic centers. Insurance type, demographic, and clinical data were collected and analyzed. In total, 466 adult patients were included in our analysis. Median follow-up after CAR-T therapy was 12.7 months. Median progression-free survival (mPFS) was longer for Caucasians (11.5 months) than for African Americans (3.5 months; hazard ratio [HR], 1.56 [1.03-2.4]; P = .04) or Asians (2.7 months; HR, 1.7 [1.02-2.67]; P = .04). Differences in median overall survival (mOS) were not significant. For Medicare (n = 206) vs Medicaid (n = 33) vs private insurance (n = 219) vs self-pay (n = 7): mPFS was 15.9 vs 4.2 vs 6.0 vs 0.9 months (P < .001), respectively; and mOS was 31.2 vs 12.8 vs 21.5 vs 3.2 months (P < .001), respectively. Our multicenter retrospective analysis showed that race and insurance status can affect outcomes for patients treated with CAR-T therapy.
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Affiliation(s)
- Reem Karmali
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Rushad Machhi
- Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Narendranath Epperla
- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University, Columbus, OH
| | | | | | - Tamara K Moyo
- Atrium Health Levine Cancer Institute, Charlotte, NC
| | - Vaishalee Kenkre
- Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | | | | | - Brian Hess
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC
| | - Kevin David
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - Ishan Roy
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Joanna Zurko
- Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Sayan Mullick Chowdhury
- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University, Columbus, OH
| | - Kaitlin Annunzio
- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University, Columbus, OH
| | | | - Rahul S Bhansali
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Elyse I Harris
- Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Jieqi Liu
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - Imran Nizamuddin
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Shuo Ma
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Jonathan Moreira
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Jane Winter
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Barbara Pro
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | | | | | - Nirav N Shah
- MCW Cancer Center, Medical College of Wisconsin, Milwaukee, WI
| | | | - Stefan K Barta
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Pallawi Torka
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Leo I Gordon
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
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Hershman DL, Vaidya R, Till C, Barlow W, LeBlanc M, Ramsey S, Unger JM. Socioeconomic Deprivation and Health Care Use in Patients Enrolled in SWOG Cancer Clinical Trials. JAMA Netw Open 2024; 7:e244008. [PMID: 38546646 PMCID: PMC10979311 DOI: 10.1001/jamanetworkopen.2024.4008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/31/2024] [Indexed: 04/01/2024] Open
Abstract
Importance Reducing acute care use is an important strategy for improving value. Patients with cancer are at risk for unplanned emergency department (ED) visits and hospital stays (HS). Clinical trial patients have homogeneous treatment; despite this, structural barriers to care may independently impact acute care use. Objective To examine whether ED visits and HS within 12 months of trial enrollment are more common among Medicare enrollees who live in areas of socioeconomic deprivation or have Medicaid insurance. Design, Setting, and Participants This cohort study included patients with cancer who were 65 years or older and treated in SWOG Cancer Research Network trials from 1999 to 2018 using data linked to Medicare claims. Data were collected from 1999 to 2019 and analyzed from 2022 to 2024. Main Outcomes and Measures Outcomes were ED visits, HS, and costs in the first year following enrollment. Neighborhood socioeconomic deprivation was measured using patients' zip code linked to the Area Deprivation Index (ADI), measured on a 0 to 100 scale for increasing deprivation and categorized into tertiles (T1 to T3). Type of insurance was classified as Medicare with or without commercial insurance vs dual Medicare and Medicaid. Demographic, clinical, and prognostic factors were captured from trial records. Multivariable regression was used, and the association of ADI and insurance with each outcome was considered separately. Results In total, 3027 trial participants were analyzed. The median (range) age was 71 (65-98) years, 1280 (32.3%) were female, 221 (7.3%) were Black patients, 2717 (89.8%) were White patients, 90 (3.0%) had Medicare and Medicaid insurance, and 660 (22.3%) were in the areas of highest deprivation (ADI-T3). In all, 1094 patients (36.1%) had an ED visit and 983 patients (32.4%) had an HS. In multivariable generalized estimating equation, patients living in areas categorized as ADI-T3 were more likely to have an ED visit (OR, 1.34; 95% CI, 1.10-1.62; P = .004). A similar but nonsignificant pattern was observed for HS (OR, 1.36; 95% CI, 0.96-1.93; P = .08). Patients from areas with the highest deprivation had a 62% increase in risk of either an ED visit or HS (OR, 1.62; 95% CI, 1.25-2.09; P < .001). Patients with Medicare and Medicaid were 96% more likely to have an ED visit (OR, 1.96; 95% CI, 1.56-2.46; P < .001). Conclusions and Relevance In this cohort of older patients enrolled in clinical trials, neighborhood deprivation and economic disadvantage were associated with an increase in ED visits and HS. Efforts are needed to ensure adequate resources to prevent unplanned use of acute care in socioeconomically vulnerable populations.
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Affiliation(s)
| | - Riha Vaidya
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Cathee Till
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - William Barlow
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mike LeBlanc
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Scott Ramsey
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Joseph M. Unger
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Mutebi M, Dehar N, Nogueira LM, Shi K, Yabroff KR, Gyawali B. Cancer Groundshot: Building a Robust Cancer Control Platform in Addition To Launching the Cancer Moonshot. Am Soc Clin Oncol Educ Book 2022; 42:1-16. [PMID: 35561297 DOI: 10.1200/edbk_359521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cancer Groundshot is a philosophy that calls for prioritization of strategies in global cancer control. The underlying principle of Cancer Groundshot is that one must ensure access to interventions that are already proven to work before focusing on the development of new interventions. In this article, we discuss the philosophy of Cancer Groundshot as it pertains to priorities in cancer care and research in low- and middle-income countries and the utility of technology in addressing global cancer disparities; we also address disparities seen in high-income countries. The oncology community needs to realign our priorities and focus on improving access to high-value cancer control strategies, rather than allocating resources primarily to the development of technologies that provide only marginal gains at a high cost. There are several "low-hanging fruit" actions that will improve access to quality cancer care in low- and middle-income countries and in high-income countries. Worldwide, cancer morbidity and mortality can be averted by implementing highly effective, low-cost interventions that are already known to work, rather than investing in the development of resource-intensive interventions to which most patients will not have access (i.e., we can use Cancer Groundshot to first save more lives before we focus on the "moonshots").
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Affiliation(s)
- Miriam Mutebi
- Breast Surgical Oncology, Aga Khan University, Nairobi, Kenya
| | - Navdeep Dehar
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Leticia M Nogueira
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Kewei Shi
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - K Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Bishal Gyawali
- Department of Oncology, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,Division of Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada
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Yabroff KR, Han X, Song W, Zhao J, Nogueira L, Pollack CE, Jemal A, Zheng Z. Association of Medical Financial Hardship and Mortality Among Cancer Survivors in the United States. J Natl Cancer Inst 2022; 114:863-870. [PMID: 35442439 PMCID: PMC9194618 DOI: 10.1093/jnci/djac044] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 11/04/2021] [Accepted: 02/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cancer survivors frequently experience medical financial hardship in the United States. Little is known, however, about long-term health consequences. This study examines the associations of financial hardship and mortality in a large nationally representative sample of cancer survivors. METHODS We identified cancer survivors aged 18-64 years (n = 14 917) and 65-79 years (n = 10 391) from the 1997-2014 National Health Interview Survey and its linked mortality files with vital status through December 31, 2015. Medical financial hardship was measured as problems affording care or delaying or forgoing any care because of cost in the past 12 months. Risk of mortality was estimated with separate weighted Cox proportional hazards models by age group with age as the timescale, controlling for the effects of sociodemographic characteristics. Health insurance coverage was added sequentially to multivariable models. RESULTS Among cancer survivors aged 18-64 years and 65-79 years, 29.6% and 11.0%, respectively, reported financial hardship in the past 12 months. Survivors with hardship had higher adjusted mortality risk than their counterparts in both age groups: 18-64 years (hazard ratio [HR] = 1.17, 95% confidence interval [CI] = 1.04 to 1.30) and 65-79 years (HR = 1.14, 95% CI = 1.02 to 1.28). Further adjustment for health insurance reduced the magnitude of association of hardship and mortality among survivors aged 18-64 years (HR = 1.09, 95% CI = 0.97 to 1.24). Adjustment for supplemental Medicare coverage had little effect among survivors aged 65-79 years (HR = 1.15, 95% CI = 1.02 to 1.29). CONCLUSION Medical financial hardship was associated with mortality risk among cancer survivors in the United States.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Weishan Song
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jingxuan Zhao
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Leticia Nogueira
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Craig E Pollack
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Zhiyuan Zheng
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
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