Socioeconomic factors a barrier to HSCT for people with acute myeloid leukemia
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Key takeaways:
- Lower neighborhood education level appeared linked to reduced likelihood of HSCT.
- Results showed no link between post-transplant mortality and median area income or neighborhood poverty level.
SAN DIEGO — Socioeconomic disparities affect access to allogeneic hematopoietic stem cell transplantation for people with acute myeloid leukemia, according to findings presented at ASH Annual Meeting and Exposition.
However, results showed no association between post-transplant mortality and factors such as neighborhood poverty level or median area income.
“If a patient gets to transplant, they can do well. It really seems from this work that the bottleneck is getting to transplant, not what happens afterward,” researcher Aaron T. Gerds, MD, MS, associate professor in medicine (hematology and medical oncology) at Cleveland Clinic Cancer Institute, told Healio.
Background
Prior research showed several factors — including age, cytogenetic risk, comorbidity burden and geriatric health — considerably affect the likelihood that individuals with AML will undergo allogeneic HSCT, as well as outcomes after transplant.
Gerds and colleagues conducted a prospective observational study to assess the role socioeconomic status had on allogeneic HSCT receipt and post-transplant mortality.
“Transplant is the only curative therapy for many patients with acute leukemias, including AML,” Gerds said. “Prior studies going back many years showed as few as 5% of eligible patients underwent transplant, and there were many reasons for that. A physician might say, ‘It's only for younger patients’ or ‘My patient isn't fit enough,’ or maybe the worry of graft-versus-host disease was too much.
"We've started to address those concerns as a community over time, and that has been in parallel with increasing interest in social determinants of health,” Gerds added. “The natural next step was to ask whether there is an association between socioeconomic status and who gets a transplant.”
Methods
The cohort included 695 people with AML treated at 13 predominantly academic centers.
Researchers assessed eight socioeconomic factors, calculating estimates based on the ZIP codes in which study participants lived.
The factors included:
- median household income;
- percentage of households below the poverty level;
- percentage of households receiving food stamps or Supplemental Nutrition Assistance Program (SNAP) benefits;
- percentage of households receiving supplemental security income (SSI), such as disability;
- percentage of adults aged at least 25 years with less than a high school education or equivalent;
- percentage of occupied housing units in which at least 30% of income is spent on housing;
- percentage of owner-occupied housing units with a mortgage that also have a home equity loan and/or second mortgage; and
- percentage of people working for pay who drive alone to work.
Investigators adjusted socioeconomic status models for several factors, including age, disease status, hematopoietic cell transplant-specific comorbidity index, Karnofsky Performance Scale, and other risk or functional assessments.
Key findings
Multivariable analysis showed a 32% reduction in likelihood of HSCT receipt for every 10% increase in percentage of residents in a particular neighborhood with less than a high school education (HR = 0.68; 95% CI, 0.55-0.84).
Results also showed a 14% reduction in likelihood of HSCT receipt for every 10% increase in households that received SNAP compared with baseline levels (HR = 0.86; 95% CI, 0.74-1).
Investigators observed what they called a “modest” increase in likelihood of HSCT for every $25,000 increase in median income compared with areas with baseline income (HR = 1.05; 95% CI, 0.94-1.18).
Likelihood of HSCT receipt declined for each 10% increase in households that received SSI (HR = 0.66; 95% CI, 0.39-1.11), as well as for each 10% increase in percentage of households below the poverty level (HR = 0.85; 95% CI, 0.7-1.03).
"I don't think it's a surprise that people from disadvantaged backgrounds get transplanted less often," Gerds said. "What we're unable to show in this analysis are some of the 'whys.' Is it bias from the local team taking care of that patient? Does it have more to do with the patients themselves? Maybe they want to stay local for their care instead of going to an academic center or a large tertiary care center for transplant. Are there financial barriers? Is it too challenging for a patient to find a relative or friend to be a full-time caregiver for 2 or 3 months? There are many possible explanations."
Access to HSCT appears to be “the primary issue,” researchers wrote, noting socioeconomic status did not appear to “definitively” impact post-transplant outcomes.
Analysis of overall post-transplant mortality showed no significant association with median area income (HR = 0.97; 95% CI, 0.57-1.66) or for every 10% increase in percentage of households below the poverty level (HR = 0.98; 95% CI, 0.61-1.57).
Researchers observed numerical increases in risk for post-transplant mortality for every 10% increase in residents with less than a high school education (HR = 1.14; 95% CI, 0.66-1.98), households receiving SNAP (HR = 1.1; 95% CI, 0.77-1.57) or percentage of households receiving SSI (HR = 1.23; 95% CI, 0.73-1.29); however, those differences did not reach statistical significance.
Next steps
Targeted interventions that expand access to HSCT for individuals from lower socioeconomic backgrounds are needed, researchers concluded.
“Health literacy is a big component,” Gerds said. “We need to educate patients and physicians about the benefits of transplant and how much better it is now than it used to be — even just 10 years ago.”
This education includes dispelling the misconception that there is “an upper age limit” for transplant, highlighting advances in GVHD treatments and other regimens that have greatly reduced rates of infection and liver toxicity, and emphasizing that nearly 80% of transplant recipients survive at least 1 year.
“We also need to address financial barriers and build systems to make it equitable,” Gerds said. “We need assistance programs that can help patients navigate the financial issues with prescription medications or address caregiver issues.
“We want everyone to have access but, as curated as transplant is, we still observe disparities,” he added. “I think this is a call to all of us to continue to push forward and try to remove barriers so patients can have access to a treatment that, quite frankly, may save their lives.”
For more information:
Aaron T. Gerds, MD, MS can be reached at gerdsa@ccf.org.
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Wuliji N, et al. Abstract 6. Presented at: ASH Annual Meeting and Exposition; Dec. 7-10, 2024; San Diego.
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