Poverty associated with transplant-related mortality among children with cancer
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Children undergoing hematopoietic stem cell transplants for cancer had higher rates of transplant-related mortality if they lived in a poorer neighborhood, according to results of a study published in Blood.
“Our study shows that even after children with cancer have successfully accessed this high-resource treatment at specialized medical centers, those who are exposed to poverty are still at higher risk [for dying of] complications after treatment and [for] dying overall,” Kira Bona, MD, MPH, attending physician at Dana-Farber Cancer Institute and Children’s Cancer and Blood Disorders Center, said in a press release. “Simply providing the highest-quality complex medical care to children who are vulnerable from a social perspective is inadequate if our goal is to cure every child with cancer.”
Poverty and other social determinants of health in the United States significantly contribute to health outcomes. However, whether these factors specifically impact outcomes of children undergoing HSCT is unknown.
To address this question, Bona and colleagues accessed the Center for International Blood and Marrow Transplant Research database to analyze data of 2,053 children with malignant conditions and 1,696 children with nonmalignant conditions undergoing allogeneic HSCT between 2006 and 2015.
Researchers used the U.S. Census definition to identify high-poverty ZIP codes as those with 20% or more of the population below the 100% federal poverty level.
Compared with children living in low-poverty neighborhoods, those living in high-poverty neighborhoods were more likely to be Black (malignant cohort, 26% vs. 9%; nonmalignant cohort, 36% vs. 17%), Hispanic (49% vs. 24%; 35% vs. 18%), and insured by Medicaid (55% vs. 31%; 58% vs. 32%).
OS, defined as time from HSCT until death of any cause, served as the primary outcome.
Relapse and transplant-related mortality in malignant disease, acute and chronic graft-versus-host-disease and infection in the first 100 days after HSCT served as secondary outcomes.
Median follow-up was 74 months (range, 3-126) for the malignant cohort and 72 months (range, 3-136) for the nonmalignant cohort.
Results showed no association between neighborhood poverty and any HSCT outcomes among children transplanted for nonmalignant disease.
For children treated with HSCT for malignancies, multivariable analysis demonstrated no association between neighborhood poverty and OS (HR = 1.04; 95% CI, 0.88-1.23), risk for relapse (HR = 0.97; 95% CI, 0.74-1.26), grade 2 to grade 4 acute GVHD (HR = 1.01; 95% CI, 0.82-1.25), chronic GVHD (HR = 1.01; 95% CI 0.77-1.32) or infection through day 100 (HR = 1.09, 95% CI 0.94-1.28).
However, children living in high-poverty neighborhoods had a higher risk for transplant-related mortality (HR = 1.34; 95% CI, 1.02-1.76).
Researchers also found that, among children in the malignant cohort, those with Medicaid experienced inferior OS (HR = 1.23; 95% CI, 1.07-1.41) and increased transplant-related mortality (HR = 1.28; 95% CI, 1.07-1.53) compared with children who had private insurance.
“We as a field need to recognize that nonbiological variables, such as your exposure to poverty and other social determinants of health, matter just as much as many of the biological variables we pay close attention to when thinking about outcomes for children, and these variables must be collected systematically for research if we want to optimize the care and outcomes of the children we serve,” Bona said.
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