Equity and Resource Allocation: The Case for Allogeneic Transplant in Emergency Medicaid Patients

• Published in: Blood 2023-11, Vol.142 (Supplement 1), p.7349-7349
• Main Authors: Hernandez, Kevin, Ahmed, Tauseef, Liu, Delong, Seiter, Karen, Steinberg, Amir
• Format: Article
• Language: English
• ISSN: 0006-4971; 1528-0020
• DOI: 10.1182/blood-2023-178225

Background:When an uninsured, undocumented immigrant presents with an emergency medical condition, they may qualify for Emergency Medicaid. Notably, the care and services related to HSCT are not covered, except in California and Washington state. Therefore, many patients with MRD-positive or relapsed ALL who may otherwise be good candidates for HSCT are unable to receive it. This may lead to months of resource-intensive treatment without the chance of cure. Here we present 3 such patients and their course of treatments and outcomes. Patient 1:A28-year-old male from Mexico was diagnosed with Ph+ B-ALL and treated with three cycles of hyper-CVAD + dasatinib. BCR-ABL PCR remained elevated at 27.9% and the patient was switched to nilotinib for 5 more cycles of hyper-CVAD; nilotinib was continued until later relapse. He began maintenance BCNU/cytoxan, then several cycles 6-MP/MTX/vincristine. On day +554 after diagnosis, he relapsed and started decitabine/venetoclax, then decadron + dasatinib, then MVP, followed by 3 cycles of inotuzumab. Later, he started blinatumomab on day +648, which was discontinued after 22 days due to increasing peripheral blasts. He then started SMILE, then CCE. As his condition worsened he was put on ponatinib, then asciminib before expiring on day +940. Patient 2: A37-year-old male from Mexico was diagnosed with CML and started on nilotinib. On day +212 he progressed to lymphoid blast phase CML with CNS involvement and received hyper-CVAD/dasatinib; was switched to nilotinib on cycle 4 due to concerns about pleural effusion while hospitalized for PNA. On day +447 he started blinatumomab + IT MTX + nilotinib. A brain MRI on day +544 suggested carcinomatous meningitis and he got 4 cycles RMVP. He then switched to ponatinib and HiDAC for 8 cycles despite continued ALL in CSF. He was admitted for worsening ALL-induced headache on day +1016 and imaging discovered multifocal pneumonia. He then had seizure-like activity consistent with metabolic encephalopathy and expired on day +1055. Patient 3: A28-year-old male from Ecuador was diagnosed with Ph+ mixed phenotype (B/myeloid) acute leukemia. The patient underwent leukapheresis and started HiDAC + mitoxantrone + etoposide + dasatinib. Subsequent bone marrow biopsy showed 1% blasts, with BCR-ABL PCR at 1.4%. He was admitted on day +170 with Ph+ B-ALL relapse and underwent leukapheresis + 2 cycles hyper-CVAD. On day +255 he began blinatumomab for 3 cycles. He continues to receive treatment for