Acute myeloid leukemia |
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Socioeconomic factors such as lower education levels and higher surrogates of poverty appear to be associated with a decreased likelihood of undergoing allogeneic hematopoietic stem cell transplantation (allo-HCT) for patients with myeloid leukemia acute (AML) and increased mortality in those who do not receive it. transplant, according to the results of a multicenter observational study presented at ASH Annual Meeting 2024.
The main socioeconomic factor, which was statistically correlated with the absence of allo-HCT, was having less than a high school diploma (adjusted HR, 0.70; 95% CI, 0 .57-0.87). Other factors were correlated, although not statistically significant. Interestingly, however, the study found that survival outcomes for those who receive a transplant are comparable across socioeconomic backgrounds.
“Once patients were able to overcome barriers and receive an (allogeneic) transplant, outcomes could be comparable regardless of socioeconomic background; however, further research is needed to validate this observation,” said lead presenter Natalie Wuliji, DO, assistant professor in the Fred Hutch Division of Clinical Research and acting instructor in the Division of Hematology and Oncology at the University of Washington School of Medicine, during a presentation results during a press briefing. “To the best of our knowledge, this is the first study to prospectively evaluate the impact of specific social determinants of health on receipt of an (allogeneic) transplant.”
During a median follow-up of 54 months, researchers examined how regional social determinants of health (SDOH) influenced 3 key outcomes: non-transplant mortality, likelihood of receiving a transplant, and post-transplant mortality. . SDOH factors, which were examined at the ZIP code level, included area housing instability, defined as the percentage of dwellings in which 30% or more of income was spent on housing or in which a second mortgage or a home equity loan has been taken out. Second, the researchers looked at transportation and the percentage of people commuting to work alone or via public transportation. These factors were further superimposed on patient and disease characteristics and quality of life/frailty measures to adjust for confounding factors, resulting in an adjusted hazard ratio (aHR).
The study enrolled 692 patients with newly diagnosed or relapsed/refractory AML between 2013 and 2017 across 13 treatment centers in the United States. The patients were mainly older adults, with a high proportion over 65 years old (43%). The Karnofsky performance score exceeded 70 for 83% of those included, with a comorbidity index specific to hematopoietic cell transplantation increased by 4 or more for 60%. The study population was predominantly white (86%) and black (6%).
Most patients had newly diagnosed AML (77%), and 14% had relapsed/refractory AML. Nearly half were considered intermediate risk by the European Leukemia Network (ELN; 43%) and 36% were considered adverse risk by the ELN. After initial treatment, 56% experienced a complete response. Overall, among the study population, 46% received allo-HCT.
For those who did not receive allo-HCT, the highest mortality rates were among patients receiving Supplemental Security Income (SSI). In this group, there was a 40% higher mortality risk without allo-HCT (aHR, 1.4; 95% CI, 1.01-1.94). Those who had not completed high school were also more likely to experience non-allo-HCT mortality, with an increased risk of 24% (aHR, 1.24; 95% CI, 1.02-1.49 ).
“Neighborhood social risk has increased, as shown here by reliance on government assistance programs, living below the federal poverty line, or having a high percentage of patients with low levels of education,” Wuliji said. “These patients were more likely to die without a transplant. The association was particularly strong for patients receiving government assistance programs, such as SSI.”
For obtaining allo-HCT, educational status again played the most important role and represented the only statistically significant factor. Participation in SSI or the Supplemental Nutrition Assistance Program (SNAP) was also a determining factor with HRAs of 0.78 and 0.91, respectively. “This highlights the critical need to address social determinants of health to ensure equitable access to curative therapies,” Wuliji said.
Once allo-HCT was received, the role of these factors appeared to have a less pronounced effect on mortality. Confidence intervals for mortality after allo-HCT were wide, with no factors reaching statistical significance. For those on SSI, the aHR was 1.22 (95% CI, 0.81-1.82). For those with less than high school education, the AHR was 1.17 (95% CI, 0.86-1.58). For those on SNAP, the aHR was 1.12 (95% CI, 0.92-1.37).
The study results suggest that once patients overcome barriers to transplant access, their outcomes align with those of their more advantaged counterparts, Wuliji said. “Overcoming these barriers could level the playing field for patients, providing comparable survival outcomes regardless of socioeconomic background.” »
The study results examined allo-HCT, but may be transferable to other costly treatment modalities for hematological malignancies, such as CAR T cell therapies, Wuliji noted. “By addressing these issues, we can ensure that all patients, regardless of their socioeconomic status, have the opportunity to benefit from potentially curative treatments,” she concluded.
Reference
Wuliji N, Gooley T, Jones S et al. Impact of socioeconomic factors on access and outcomes of allogeneic hematopoietic cell transplantation (allo-HCT) for acute myeloid leukemia (AML): a multicenter observational study. Presented at: ASH Annual Meeting and Exhibition 2024; December 7-10, 2024; San Diego, California. Summary 6.