Travel time and insurance status as determinants of specialized leukemia care access in adolescents and young adult (AYA) patients with acute lymphoblastic leukemia (ALL)

Abstract

Abstract Background: NCCN guidelines for ALL state that patients should undergo evaluation and treatment at specialized [cancer] centers (SCC). Studies across U.S. states confirm that AYAs with ALL have superior outcomes following treatment at SCCs; however, fewer than half of AYAs >18 years receive care at these centers (Muffly et al JCO OP 2023). Interviews with hematologists and policy makers describe travel time and health insurance as perceived barriers to accessing SCCs (Muffly et al JNCCN 2025). Using a quantitative, population-based approach, we examined the association of travel time and health insurance coverage at diagnosis on ALL treatment at SCCs. Methods: AYAs 15-39 years when newly diagnosed with ALL between 2004-2018 and reported to state cancer registries in California (CA), New York (NY), or Texas (TX) were included. SCC was defined as either an NCI-Designated Cancer Center (NCI-DCC) or Children's Oncology Group (COG) site. Admissions-level data were used to determine treating facility. Travel time to treatment facility and to closest SCC were calculated as one-way driving time between population-weighted zip code centroid for each patient and facility address. For patients 15-20 years, closest SCC was designated as either the closest COG or NCI-DCC facility; for patients 21-39 years, only NCI-DCCs were considered. ESRI ArcGIS Pro version 3.3.0, StreetMap Premium 2024 Q1 North American Locator was used for Geocoding. Logistic regression evaluated associations between travel time and health insurance with treatment at an SCC, adjusting for age, sex, race/ethnicity, diagnosis year, and poverty quintile. Results: The cohort included 4,211 newly diagnosed AYAs with ALL (CA 2514, NY 853, TX 981). A majority (59.4%) were 18-39 yrs, 65.7% were male, 57.0% were Hispanic. Age/sex distribution were similar across states, while race/ethnicity differed, with Hispanic patients comprising 62.5% in CA, 32.0% in NY, and 64.6% in TX. In total, 2296 (54.5%) were treated at an SCC; more AYAs in CA (61.5%) and NY (60.9%) received care at SCCs than in TX (27.3%). Overall, 56.2% lived ≤30 minutes from an SCC (CA 57.8%, NY 61.1%, TX 46.5%), while 22.1% lived >60 minutes from an SCC (CA 19.8%, NY 19.0%, TX 31.8%). Among AYAs treated at nonSCCs (n=1780), 28% and 24% lived equidistant or closer to an SCC than to the treating nonSCC facility, respectively; 10% were >60 minutes further from an SCC. Associations between travel time and treatment at an SCC were inconsistent across states: relative to a travel time of <15 minutes to an SCC, travel time of 31-60 minutes (odds ratio (OR) 0.4, 95% confidence interval (CI): 0.3-0.7) or >60 minutes (OR 0.1, CI: 0.1-0.3) was associated with lower odds of treatment at an SCC in NY;, but not in CA or TX. Across the whole cohort, private (47.1%) health insurance was most common, followed by Medicaid (30.7%), Medicaid Managed Care (8.2%), uninsured (6.0%), other public (4.8%), and unknown insurance (3.3%). More patients in TX were uninsured (17.8%) than in CA (2.7%) or NY (4.0%). Among insured patients, 51.9%, 43.1%, and 43.7% were publicly insured in CA, NY, or TX, respectively. In all states, relative to private insurance, uninsured status was significantly associated with a lower odds of treatment at an SCC (CA OR 0.4, CI: 0.2-0.7; NY OR 0.4, CI: 0.2-0.9; TX OR 0.3, CI: 0.2-0.6). Medicaid coverage was associated with a marginally higher odds of treatment at an SCC in CA (OR 1.2, CI: 0.99-1.5) while both Medicaid (OR 0.6, CI: 0.4- 0.9) and Medicaid Managed Care (OR 0.1, CI: 0-0.3) were associated with a lower odds of treatment at an SCC in TX. We examined interactions between travel time and health insurance in each state and found no significant interactions in any models. Conclusions: In this population-based study including three large and diverse states, approximately half of AYA ALL patients treated at non-SCC facilities would not have to travel farther to reach the closest SCC. Further travel time reduced the likelihood of treatment at an SCC only in NY, suggesting that other factors, such as patient or clinician preferences, are impacting location of care. AYAs lacking insurance were less likely to receive treatment at SCCs in all states studied. Therefore, health policies that have the potential to further reduce insurance access will worsen outcomes for this patient population.