Insurance Status Contributes to Survival Disparities in Follicular Lymphoma

Patients with follicular lymphoma (FL) who have private health-care insurance live longer than uninsured patients or those who are enrolled in Medicare, according to a study published in Blood. Lead author Jordan S. Goldstein, MD, from Winship Cancer Institute at Emory University in Atlanta, and colleagues, commented that the results suggest that “expanding access to care through insurance has the potential to improve FL outcomes.”

While previous research has demonstrated that lower socioeconomic status is associated with poor outcomes in FL, the association between outcome and other social determinants of FL prognosis, like insurance status, have not been sufficiently examined, the authors explained.

In the analysis, researchers used the National Cancer Database (NCDB; a nationwide, hospital-based cancer registry sponsored by the American Cancer Society and the American College of Surgeons) to identify 43,648 patients diagnosed with FL between 2004 and 2014.

All analyses were performed on two cohorts – patients <65 years (n=22,133) and patients ≥65 years (n=21,515) – to account for changes in insurance status with Medicare eligibility.

Insurance status among the entire cohort was:

  • privately insured: 47% (80% for <65 years and 13% for ≥65 years)
  • uninsured: 3% (6% and <1%)
  • Medicaid-insured: 4% (6% and <1%)
  • Medicare-insured: 46% (8% and 86%)

Patients with no insurance or Medicaid were more likely to be black or Hispanic, to live in an area with lower levels of educational achievement, on average, to have B-symptoms, and to be diagnosed at an advanced stage, compared with those with private insurance or Medicare (p<0.001 for all comparisons).

Over a median follow-up of 57.9 months in the younger cohort and 42.8 months in the older cohort (ranges not provided), 11,547 patients died (26%).

For younger FL patients, median overall survival (OS) was 92 percent at 3 years, 88 percent at 5 years, and 84 percent at 7 years. In the older cohort, OS rates were 73 percent, 63 percent, and 52 percent, respectively.

Compared with patients <65 years with private insurance, the prognosis was significantly worse for those with no insurance, Medicaid, or Medicare:

  • no insurance: hazard ratio (HR) for OS=1.96 (95% CI 1.69-2.28; p<0.0001)
  • Medicaid: HR for OS=1.82 (95% CI 1.57-2.12; p<0.0001)
  • Medicare: HR for OS=1.96 (95% CI 1.71-2.24; p<0.0001)

In the ≥65 years group, patients with Medicare also had a statistically significantly worse OS than privately insured patients (HR=1.28; 95% CI 1.17-1.4; p<0.0001).

These associations remained significant after adjusting for sociodemographic, prognostic, and treatment factors, the researchers noted. Disease stage, presence of B-symptoms, and comorbidities were significant predictors of FL survival in patients, “contributing to the survival disparities seen with insurance status.” However, the authors contended, “although stage is an important factor in how insurance status relates to FL survival, [it] does not fully explain the disparate outcomes and lead-time bias is unlikely to be the sole source for this difference.”

Based on their findings, the authors concluded that studies of outcomes in FL should include insurance status as a predictor. “Further research on prognosis for FL should examine the impact of public policy … [and] other factors that influence access to care, such as individual-level socioeconomic status, regular primary-care visits, access to prescription medications, and care affordability [related to FL outcomes],” they added.

Because the analysis relied on the retrospective NCDB, the authors were not able to control for all possible confounders, which they noted as a limitation of the study. Potential confounders included individual-level socioeconomic status, health literacy, and adherence to follow-up – all of which were excluded from the registry.

The authors report financial relationships with AbbVie, Spectrum, Seattle Genetics, Gilead Sciences, and Bayer. The study was supported with funding from the National Institutes of Health.


Goldstein JS, Nastoupil LJ, Han X, et al. Disparities in survival by insurance status in follicular lymphoma. Blood. 2018 July 14. [Epub ahead of print]