Survival after first relapse of pediatric B-ALL differs by insurance type: A real-world analysis from the recall-1 study
Year: 2025
Type: conference-abstract
Abstract: BACKGROUND Children exposed to poverty during frontline therapy for B-lymphoblastic leukemia (B-ALL) experience inferior overall survival (OS), higher relapse rates, and earlier relapse than their peers. Real-world data describing treatment patterns and survival after relapse of B-ALL are lacking and, as a result, the impact of poverty following relapse remains poorly understood. This study evaluated the association of poverty exposure, proxied by insurance status, with post-relapse survival and explored potential explanatory mechanisms, including disease biology and therapy utilization. METHODS Data from Retrospective Study of Contemporary Approaches to First Relapse in B-ALL (ReCALL-1), a multicenter retrospective cohort study of patients < 30 years old with first relapse of B-ALL from 2018-2022, were used. The primary exposure was poverty, proxied by insurance status at relapse, categorized as any private insurance (poverty unexposed), public-only insurance (poverty exposed), no insurance, or unknown; the latter two were not included in comparative analyses due to low numbers. The primary outcome was OS. Secondary outcomes included measurable residual disease (MRD)-negative second complete remission (CR2), relapse after CR2, non-relapse mortality (NRM), with relapse treated as a competing risk, and receipt of cellular and immunotherapies. RESULTS Among 462 patients from 31 U.S. institutions, 41% had private insurance, 47% public-only insurance, 2% no insurance, and 10% unknown. Compared to privately insured patients, those with public insurance were more likely to be Hispanic (56% vs 19%, p<0.001) and have non-English preferred language (30% vs 6%, p<0.001). Non-Hispanic Black patients comprised 9% of those with public insurance and 5% of those with private insurance. Disease characteristics that differed by insurance status at relapse included: Ph-like cytogenetics, more common in publicly insured (23% vs 11%, p=0.002), and infant ALL, more common in privately insured patients (10% vs 5%, p=0.06). Publicly insured patients were more likely to have experienced major organ toxicity during frontline therapy (32% vs 18%, p=0.002) and very early relapse (<18m from diagnosis: 43% vs 32%, p=0.07). Other demographic and disease characteristics, including relapse site and cytomolecular features, were similar by insurance status. With a median follow-up of 51 months from relapse, 4-year OS differed by insurance (log-rank p=0.02): 72% for private vs 56% for public insurance. After adjusting for race/ethnicity and language, public insurance increased the hazard of death by 65% (aHR 1.65 95% CI 1.13-2.42, p=0.004). The association remained, but was attenuated, when unbalanced disease characteristics (time to relapse, infant ALL, Ph-like cytogenetics, prior organ dysfunction) were included (aHR 1.47, 95% CI 1.00-2.16, p=0.05). Rates of MRD-negative CR2 were similar (85% public vs 87% private). However, point estimates suggested publicly insured patients had more relapse after CR2 (44% vs 37%, p=0.42) and higher 4-year NRM (16% vs 10%, Gray's test p=0.12), though neither were significant. Treatment choices for first relapse did not differ by insurance status. Utilization of intensive reinduction (91% vs 95% for public vs private, p=0.18) and clinical trial enrollment (22% for both) were similar. Receipt of cellular therapies did not significantly differ by public vs private insurance: Chimeric Antigen Receptor-T cells (CAR-T: 38% vs 34%, p=0.41), hematopoietic cell transplant (HCT: 42% vs 47%, p=0.32). Use of blinatumomab trended higher in those with private insurance (36% vs 45%, p=0.07), and inotuzumab was similar (11% for both, p=0.87). Median time from relapse to CAR-T or HCT was comparable (to CAR-T 102 vs 100 days, to HCT 117 vs 114 days). CONCLUSION This is the first study to demonstrate differential survival by insurance type, a proxy for poverty exposure, after first relapse of B-ALL. In this large multicenter, real-world cohort, patients with public insurance had worse OS after relapse than those with private insurance. The survival disparity existed independent of other SDOH factors. Adjustment for known high-risk disease features only partially accounted for the observed differences in OS. In contrast, rates of MRD-negative CR2 and receipt of CAR-T and HCT were comparable across insurance types. These findings highlight the urgent need to identify effective interventions that will ensure equitable outcomes after relapse.
Source: Blood
Authors: Katherine Lind, Abigale Berry, Yimei Li, Hongyan Liu, Jeremy Rubinstein, Gabriella Nguyen, Vanessa Fabrizio, Anurekha Hall, Deepa Bhojwani, Troy Quigg, Shannon Maude, Nirali Shah, Maria Ortega, Abdulla Al-Mulla, Ibrahim Ahmed, Jill Beck, Deepika Bhatla, Eliza Briscoe, Roland Chu, Laurie Davis, J. Gregory Dolan, Jennifer Drinkwine, Anna Elias, Lyannette Elo, Elizabeth Eom, Kelly Faulk, Erin Goode, Darcy Hamill, Miza Salim Hammoud, Ashley Hinson, Alex Hoover, Hannah Kinoshita, Mira Kohorst, Elizabeth Krieger, Cathy Lee-Miller, Kevin McNerney, Jordan Milner, Amy Moskop, Giselle Moore-Higgs, Lindsey Murphy, Megan Murphy, Hiren Patel, Thomas Pfeiffer, Alexandra Prosser-Dombrowski, Mahvish Rahim, April Rahrig, Amanda Saraf, Jamie Shoag, Heather Symons, Nicholas Tastet, Stephanie Thomas, Molly Thornock, Keri Toner, Smitha Vasanna, Alejandra Escobar Vasco, Allison Weisnicht, Sara Zarnegar-Lumley, Lena Winestone, Regina Myers, Caitlin Elgarten
Institutions: Medical College of Wisconsin, Children's Hospital Colorado, University of Colorado Anschutz, Children's Hospital of Philadelphia, Cincinnati Children's Hospital Medical Center, University of Cincinnati, The University of Texas Southwestern Medical Center, Seattle Children's Hospital, Children's Hospital of Los Angeles, Helen DeVos Children's Hospital, National Institutes of Health, National Cancer Institute, Center for Cancer Research, Virginia Commonwealth University, Children's Hospital of Richmond at VCU, Children's Mercy Hospital, Nebraska Medical Center, University of Nebraska Medical Center, Cardinal Glennon Children’s Medical Center, Saint Louis University, University of Utah, Mayo Clinic, Cleveland Clinic, Levine Children's Hospital, Wake Forest University, University of Minnesota, Children's National, George Washington University, Center for Cancer and Blood Disorders, University of Wisconsin–Madison, Lurie Children's Hospital, University of Florida, City Of Hope National Medical Center, City of Hope, Johns Hopkins University, Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Cohen Children's Medical Center, Washington University in St. Louis, Children's Hospital at Montefiore, Indiana University School of Medicine, Riley Hospital for Children, Arkansas Children's Research Institute, Northwestern University, University of California, San Francisco
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4417018757
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