Natalie Wuliji, DO

A large prospective observational study of patients with acute myeloid leukemia (AML) has found that lower socioeconomic status is a barrier to accessing hematopoietic cell transplantation (HCT) but does not affect posttransplant outcomes. Interventions that address financial issues, improve health literacy, and boost support systems are needed to ensure equitable access to life-saving cancer treatments for patients, according to the study authors. The study was presented by lead author Natalie Wuliji, DO, a hematologist-oncologist at Fred Hutch Cancer Center, Seattle, during the Plenary Session at the 2024 American Society of Hematology (ASH) Annual Meeting & Exposition (Abstract 6).

A growing number of studies suggest that patients with cancer who face socioeconomic disadvantage are less likely to receive cancer treatment, more likely to experience greater delays in beginning therapy, and less likely to receive high-quality treatment.

“This study was born out of our clinical observations that if we could get a low socioeconomic patient over the transplant access barrier, their survival outcomes were equivalent to individuals with higher socioeconomic status,” said Dr. Wuliji. “With this analysis confirming our initial theory, we can now take steps toward solving the challenge of transplant access.”

Study Methodology

The researchers analyzed several socioeconomic status factors as estimated by patients’ zip codes, including median household income; percentage of adults aged ≥ 25 years with a high school education or equivalent; percentage of households below the poverty level; percentage of households receiving Supplemental Nutrition Assistance Program (SNAP) food stamps; percentage of occupied housing units (rented and owner-occupied) in which 30% or more of income is spent on housing; percentage of owner-occupied housing units with a second mortgage, home equity loan, or both; percentage of households receiving Supplemental Security Income (SSI) disability; and percentage of people working for pay who drive to work alone.

They used the Fine-Gray regression model to evaluate factors influencing the receipt of HCT, in which death without the therapy was treated as a competing risk. For overall mortality after HCT, Cox regression with left truncation at HCT was employed. All socioeconomic factors were modeled as continuous linear variables, with hazard ratio (HR) presented in terms of an increase in income of $25,000 and an increase in percentage of other factors of 10%. In addition, each socioeconomic model was adjusted for age, HCT-specific comorbidity index, disease status, European LeukemiaNet risk stratification for AML, Karnofsky performance scale, Patient Health Questionnaire–9, Activities of Daily Living, 4-Meter Walk Test, and Functional Assessment of Cancer Therapy Scale.

Key Results

In the researchers’ analysis of 695 patients with AML, they found a decrease in the likelihood of HCT receipt by 32% as the percentage of residents with less than a high school education in a neighborhood increased by 10% (HR = 0.68, 95% confidence interval [CI] = 0.55–0.84, P = .0005). They also observed a 14% decrease in the likelihood of receiving allogeneic HCT for each 10% increase in households receiving SNAP benefits compared with baseline levels (HR = 0.86, 95% CI = 0.74–1.00, P = .04).

In contrast, increase in the likelihood of HCT receipt was modest (5%) as median area income increased by $25,000 compared with baseline levels (HR = 1.05, 95% CI = 0.94–1.18, P = .39). There was also a small decrease (15%) in the likelihood of HCT receipt for each 10% increase in the percentage of households below the poverty level (HR = 0.85; 95% CI = 0.70–1.03, P = .10) but a larger decrease (34%) for each 10% increase in households receiving SSI disability benefits (HR = 0.66, 95% CI, 0.39–1.11, P = .11).

The researchers found little evidence of an association between median area income and overall mortality after HCT (HR = 0.97, 95% CI = 0.57–1.66, P = .92). There was a numerical increase in hazard of mortality after HCT, as the percentage of residents with less than a high school education in a neighborhood increased by 10%, but the increase was modest (HR = 1.14, 95% CI = 0.66–1.98, P = .64); little evidence of an increase or decrease in mortality as the percentage of households below the poverty level increased by 10% (HR = 0.98, 95% CI = 0.61–1.57, P = .92); and numerical (but modest) increases in mortality as the percentage of households receiving SNAP benefits increased by 10% (HR = 1.10, 95% CI = 0.77–1.57, P = .60); and as the percentage of households receiving SSI benefits increased by 10% (HR = 1.23; 95% CI = 0.73–1.29, P = .40).

Clinical Significance

Mohamed Sorror, MD, MSc

“This study has highlighted the need for targeted interventions to improve access for patients from lower socioeconomic backgrounds,” said Mohamed Sorror, MD, MSc, senior author and clinical researcher at Fred Hutch Cancer Center. “We need to focus on addressing financial barriers, improving health literacy, and enhancing support systems to ensure equitable access to treatments.”

Further, the study authors concluded: “These findings underscore potential impact of socioeconomic disparities on receipt of HCT in AML patients. Lower educational attainment could be a barrier to receiving HCT. This suggests the primary issue is access to HCT, as [socioeconomic status] does not seem to definitively affect post-transplant outcomes among those who receive HCT. This highlights the need for targeted interventions to improve access to HCT for patients from lower socioeconomic backgrounds. Efforts should focus on addressing financial barriers, improving health literacy, and enhancing support systems to ensure equitable access to life-saving treatments.”

Disclosure: Dr. Wuliji serves on a board of directors or advisory committee for MustangBio. Dr. Sorror has served as a consultant and received honoraria from Jazz Pharmaceuticals. For full disclosures of all study authors, visit ash.confex.com.