Global socioeconomic disparities in patients with ALL: Key updates from ASH 2022

For patients with acute lymphoblastic leukemia (ALL), socioeconomic factors can have a serious influence on patient quality of life and disease outcome. The ALL Hub has previously reported on socioeconomic challenges in the diagnosis and treatment of patients with ALL.

During the 64th American Society of Hematology (ASH) Annual Meeting and Exposition, a number of key sessions were presented addressing global socioeconomic disparities in patients with ALL including race, geographic location, access to adequate levels of cancer treatment, and household poverty levels; these are all important factors affecting disease outcomes in these patients. Below, we provide a brief overview of the key outcomes of each presentation.

Addressing racial disparities to advance quality care for adults with ALL: a health equity-focused quality improvement program¹

Patel presented a poster on the impact of racial disparities on the quality of care received by adults with acute leukemia, including adults with ALL. These disparities have existed for many years, largely due to multi-level etiologies. In order to properly assess these differences, the investigators developed a two-center health equity-focused quality improvement program to assess acute leukemia practice patterns as well as patient- and health system-level barriers to evidence-based, equitable, and patient-centered care in two community oncology practices.

As part of the program, 102 patients completed surveys designed to evaluate self-reported practice patterns, challenges, and barriers to equitable care. In addition, 30 hematology/oncology healthcare professionals also completed the surveys along with live 1-hour audit-feedback sessions conducted in small groups.

Author’s conclusions

Overall, the results of the surveys and feedback sessions identified access to care, effective shared decision-making, and clinical trial enrollment as the main barriers to providing equitable, patient-centered care. Additionally, inadequate access to transportation for Black patients and access to translators/translated material for Hispanic patients were identified as important racial disparities.

Outcomes of elderly patients with acute lymphoblastic leukemia: trends of survival in the last two decades²

Gupta presented a poster on the outcomes facing elderly patients with ALL, focusing on survival trends over the last 2 decades and the impact of therapeutic advancements including novel agents, such as tyrosine kinase inhibitors, inotuzumab ozogamicin, blinatumomab, and CAR T-cell products. Survival outcomes based on demographic and genetic features were also evaluated.

The investigators identified 2,936 patients ≥65 years of age that were suitable for survival analysis. Subgroup analysis included factors such as immunophenotypic subtype, mutational status, ethnicity, sex, age, and year of diagnosis. Years of diagnosis were divided into three study time periods (TPs) (TP1, 2000–2005; TP2, 2006–2011; TP3, 2012–2018) to assess the effect of changing management strategies.

Overall, in the past 2 decades, the prognosis for elderly patients with ALL showed improvement, with particularly notable improvements seen in patients with the t(9;22) mutational status. In survival analysis, superior outcomes were seen in patients with t(9;22) B-cell ALL. In subgroup analysis, survival improved over the three time periods (Table 1).

Table 1. Survival outcomes in different subgroups over the three time periods*

Author’s conclusions

The overall prognosis for elderly patients diagnosed with ALL showed improvement over the last 2 decades, with notable improvements being observed in patients with t(9;22) mutational status. In addition, the study highlighted racial disparities affecting survival outcomes for Non-Hispanic Black patients and areas of unmet need in racial minorities, patients aged >75 years, and patients with T-cell immunophenotype.

Geographical barriers to accessing specialty cancer care among adolescents and young adults with acute lymphoblastic leukemia³

Muffly spoke on geographical barriers as a determinant of access to specialty cancer care for adolescents and young adults (AYA) patients with ALL in the United States (U.S.). Access to frontline ALL treatment at a specialty cancer center (SCC) has previously been identified as an important factor conferring a survival benefits to these patients.

The investigators presented a population-based analysis, detailing the geographical distribution of U.S. AYA patients with ALL relative to SCCs, while also identifying patients most at risk of severe geographical barriers to SCC-level care. In the context of this study, SCCs were defined as National Cancer Institute Designated Cancer Centers (NCIDCC) and/or Children’s Oncology Group (COG) sites. Additionally, NCI Community Oncology Research Program (NCORP) sites were also included for analysis.

Nearly half of the newly diagnosed AYA patients with ALL in the U.S. had severe access problems due to their distance from NCI-designated cancer centers. There was greater geographic accessibility to COG centers; only 25% of newly diagnosed AYA patients were required to drive >1 hour to access treatment. Counties with a long travel distance to SSC care are defined independently by factors such as rurality, lower education, greater income-inequality, and chemotherapy-providing hospitals.

Authors’ conclusions

Whilst AYA patients with ALL experience improved survival when receiving treatment at an SCC, significant geographic barriers exist limiting access this level of care across the U.S., particularly at NCIDCC sites. Future studies are required to fully comprehend the role of NCORP in AYA ALL because NCORR sites are geographically more accessible than NCI-designated cancer centers across the U.S.

Poverty during maintenance and relapse risk in children with acute lymphoblastic leukemia: a report from Children’s Oncology Group study (COG-AALL03N1)⁴

Wadhwa discussed poverty levels among patients with ALL during maintenance treatment and how this affects relapse risk. Historically, there has been mixed evidence regarding this association, with most studies relying on potentially unreliable indicators of household poverty.

In this secondary analysis of the COG-AALL03N1 trial (NCT00268528), investigators used the Centers for Disease Control (CDC) national yearly median poverty thresholds along with self-reported annual household income data to determine poverty levels among the 592 eligible patients. The study examined the association between poverty and risk of relapse, compared if adherence to oral mercaptopurine (6MP) differs between patients living in poverty vs non-poverty, and examined if 6MP adherence partly explains the hazard of relapse in children with ALL living in poverty.

At baseline, 12.3% of children with ALL were living in extreme poverty. Non-White race/ethnicity and low parental education were associated with greater odds of living in extreme poverty (p = 0.004). The cumulative incidence of relapse at 3 years from study entry among patients living in extreme poverty was higher compared with those not living in extreme poverty (14.3% vs 7.6%; p = 0.04). Patients living in extreme poverty had a ~2-fold higher hazard of relapse compared with those not living in extreme poverty after adjusting for the above-mentioned covariates (p = 0.04). Children living in extreme poverty had significantly lower adherence to 6MP compared with those not living in extreme poverty (<95% adherence to 6MP was associated with a 2.7-fold increased risk of relapse; p = 0.04).

Author’s conclusions

Extreme household poverty was associated with an increased hazard of relapse in children receiving maintenance therapy for ALL. Children living in extreme poverty were significantly less likely to achieve the critical adherence required to maintain durable remission. The precise underlying reasons for this correlation are unclear at this time and will need to be explored further in future studies.

Access and treatment equity across the Comprehensive Cancer Center catchment area: targets for disparities remediation in acute leukemia research participation⁵

Hantel spoke about race-ethnic disparities in the acute leukemia research population and how these can limit generalizability and equitable access to novel therapies.

In this study, the investigators examined hospital access and initial treatment data for the Dana-Farber Cancer Institute (DFCI) relative to its catchment area for all patients diagnosed with acute myeloid or lymphoblastic leukemia over a 4-year period.

Overall, 469 patients with ALL accessed DFCI (186 patients accessed outside MA and 283 patients accessed inside MA). Access to DFCI within the catchment area was not significantly different based on race/ethnicity. Non-Hispanic White patients were more likely to access DFCI from outside the catchment area and have initial treatment at DFCI. Targetable groups for remediating equitable care at this large SCC hospital include diverse race/ethnicity access and initial treatment provision for older patients and those with ALL.

Authors’ conclusions

Overall access to leukemia care did not significantly differ by race/ethnicity, this suggests that equitable care for patients is achievable across races at other similar cancer-care sites. Disparities in initial treatment within the catchment area and access from outside define targetable problems that affect how fairly under-enrolled populations can participate in clinical research. The next steps could involve comparing enrollment and access data and creating tools for real-time, citizen-based diversity monitoring.