Extreme poverty linked to nearly twofold higher risk for relapse among children with ALL
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Key takeaways:
- Poor adherence to maintenance therapy did not fully explain the association.
- The findings highlight the negative effects social determinants of health have on children with ALL, a researcher told Healio.
Children with acute lymphoblastic leukemia receiving maintenance therapy who lived in extreme poverty had nearly double the risk for relapse compared with children who did not live in extreme poverty, according to data published in Blood.
Poor adherence to mercaptopurine did not fully explain the association, researchers wrote.
“This highlights the negative effects social determinants of health, such as poverty, have on children with acute lymphoblastic leukemia,” Aman Wadhwa, MD, MSPH, pediatric oncologist and health sciences researcher in the division of pediatric hematology and oncology at The University of Alabama at Birmingham, told Healio. “While we identified adherence to oral chemotherapy to be lower among those living in poverty, adjusting for low adherence in models examining relapse minimally affects relapse risk. This indicates that poverty may have other effects that increase the risk [for] relapse.”
Background and methodology
Wadhwa and colleagues conducted a secondary analysis of the COG-AALL03N1 study to identify potential associations of individual poverty level and relapse among children with ALL receiving maintenance therapy.
They categorized patients living below year-specific federal poverty thresholds using U.S. Census Bureau data, with participants living 120% below federal poverty thresholds designated as living in extreme poverty.
Researchers estimated hazard of relapse using multivariable proportional sub-distributional hazards regression for patients living in extreme poverty as they received maintenance therapy after adjusting for relevant predictors.
The analysis included 592 patients (median age, 5 years; range, 1-19; 68.4% male), of whom 12.3% lived in extreme poverty.
Researchers reported median follow-up of 7.9 years.
Results
The findings showed significantly higher cumulative incidence of relapse at 3 years from study enrollment among patients with ALL living in extreme poverty (14.3%; 95% CI, 7.3-23.6) compared with those not living in extreme poverty (7.6%; 95% CI, 5.5-10.1).
Multivariable analysis showed those living in extreme poverty had a 1.95-fold (95% CI, 1.03-3.72) greater risk for relapse than those not living in extreme poverty. Adjustment for race and ethnicity reduced the relapse hazard among these children (HR = 1.68; 95% CI, 0.86-3.28).
Researchers found children living in extreme poverty to be more likely to be nonadherent to mercaptopurine than those not in extreme poverty (57.1% vs. 40.9%); however, poor adherence did not fully explain the association between poverty and relapse risk.
Next steps
Future studies seek to understand the mechanisms behind the association between extreme poverty and relapse risk, according to researchers.
“The next steps, which are ongoing, need to examine whether alleviating material hardships can improve the outcomes of patients,” Wadhwa told Healio. “Our study was also not able to account for certain key characteristics that predict relapse risk, such as minimal residual disease, or recently identified high risk groups of ALL due to the time when it was conducted. Future studies need to adjust for these factors when assessing poverty and relapse risk.”
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