Socioeconomic Disparities in Allogeneic Hematopoietic Cell Transplant Outcomes
Authors: Shahzad Moazzam , Sarfraz Zouina , Ponvilawan Ben , Amin Muhammad Kashif , Gupta Ankita , McGuirk Matthew , Chaudhary Sibgha Gull , Anwar Iqra , Shune Leyla O. , McGuirk Joseph P. , Hamadani Mehdi , Mushtaq Muhammad Umair 
Published: December 2024

Background: Allogeneic hematopoietic cell transplantation (HCT) is a vital therapy option for several hematological disorders. Significant socioeconomic disparities exist in access and outcomes, particularly among minority and low-income populations. This study aimed to investigate the impact of socioeconomic factors on outcomes following allogeneic HCT.

Methods: We conducted a retrospective analysis using the P-5805 dataset from the publicly available Center for International Blood and Marrow Transplant Research (CIBMTR). The dataset includes data from 121 patients who underwent allogeneic HCT, with information on social determinants of health and clinical characteristics. The study's median follow-up time was 73 months (range 13-98). Primary outcomes were overall survival (OS) and disease-free survival (DFS). Secondary outcomes included acute graft-versus-host disease (aGVHD), chronic GVHD (cGVHD), neutrophil and platelet engraftment, relapse, and non-relapse mortality (NRM). Statistical analyses included Chi-squared tests and Cox regression analyses. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated, and statistical significance was defined as p &lt;0.05.

Results: The median age of patients was 54.3 years (range 18.1-73.9); 58% were male, and 91% were Caucasian. Seventeen patients (15%) lived in neighborhoods with at least 20% of residents below the poverty line. Fifty-six patients had available household income data, with 37.5% earning less than $60,000 annually. Sixty patients (55%) had full-time occupations, and 61% had private or employer-based insurance. Primary diagnoses included acute myeloid leukemia (35%), myelodysplastic syndromes and myeloproliferative neoplasms (27%), lymphoma (20%), acute lymphoblastic leukemia (11%) and others (7%). Myeloablative conditioning was used in 53% of patients. Donor types were matched unrelated (73%), mismatched unrelated (11%), and cord blood (16%). Graft sources were bone marrow (17%), peripheral blood stem cells (67%), and cord blood (16%). GVHD prophylaxis regimens included CD34 selection (70%), Tacrolimus/Cyclosporine-based (13%), and others (17%). Race, gross household income, neighborhood poverty level, marital status, work status, and insurance type were correlated with post-transplant outcomes. Patients from high-poverty neighborhoods had worse OS (HR=1.85, 95% CI 1.01-3.43, P=0.05), higher grade III-IV aGVHD (HR 4.05, 95% CI 1.24-12.98, p=0.01) and a trend towards poor DFS (HR=1.76, 95% CI=0.93-3.31, P=0.08). African American patients had a trend towards higher grade III-IV aGVHD (OR=4.67, 95% CI=0.97-22.64, P=0.03). Lower household income was associated with a decreased likelihood of extensive cGVHD (OR=0.29, 95% CI=0.07-0.99, P=0.04).

Conclusions: Socioeconomic factors significantly influence outcomes after allogeneic HCT. However, a small sample size limits the data, and further studies investigating the impact of sociodemographic factors are warranted in a representative transplant cohort.