Effects of socio-economic status and gender on non-relapse mortality after allogeneic stem cell transplant.
Authors: Varshavsky Yanovsky Asya , Egleston Brian L. , Shestovska Yuliya , Ahr Katya , Mandzhieva Dzhirgala , Senchak Jordan , O'Brien Jenny , Styler Michael , Khanal Rashmi , Abdelmessieh Peter , Fung Henry C. 
Published: June 2023

e18600

Background: Allogeneic stem cell transplant (allo SCT) is a potentially curative therapy for hematological malignancies but is associated with high treatment related non-relapse mortality (NRM). Post-transplant care requires large amount of healthcare and patient resources, imposing higher burden on patients with lower socio-economic status (SES). Adverse health outcomes have been noted in males from lower SES background. We analyzed the effects of social factors on post-transplant survival and NRM in the diverse patient population treated at our institution. Methods: We retrospectively reviewed patients who underwent allo SCT at our program in 2015-2021. We collected baseline patient (demographics, KPS, HCT-CI), disease (diagnosis, risk index) and transplant characteristics (donor type, conditioning intensity). We extracted neighborhood level income data from US Census. Primary outcomes were survival and NRM. We used Fisher’s Exact, Wilcoxon Ranksum tests and logistic regressions. Results: 210 patients (116 males and 94 females) were included in the analysis. Neighborhood level estimated household income range was $26,041-163,074. Both 1 year OS and NRM, but not 100 days OS, significantly correlated with income. Patients who were alive at 1 year follow up (74.8% pts) had median income of $72K, compared to $62K for patients who died before 1 year (25.2% pts) and 60.5K for patients who died before 1 year without disease progression (13.3% pts) (p 0.032). The effect of income on NRM remained significant on multivariable analysis, adjusted for year of transplant, age, race, ethnicity, donor type, KPS, comorbidity index, regimen intensity, and disease risk. Increased conditioning intensity and haplo donor were also associated with increased 1 year NRM, while race and ethnicity did not have significant effect on 1 year NRM on multivariable analysis. The effect of income on NRM was dramatically different in male vs female patients. In men, a $10K increase in neighborhood income reduced the odds of NRM substantially (OR = 0.46, 95% CI 0.28-0.75), while in women there was no effect (OR 1.02, 95% CI 0.71-1.45). 1 year NRM in men was 9% vs 24% for higher vs lower neighborhood income (p 0.036), and in women 8% vs 13% (p 0.52). Conclusions: Our study identifies male patients residing in lower income neighborhoods as a subgroup at increased risk for NRM after allo SCT, after adjustment for the biological variables. The negative effects of lower neighborhood income and male gender become apparent with 1 year but not 100 days follow up, reflecting increasing difficulties with high resourses utilization over prolonged time period. Careful evaluation of controllable risk factors and optimizing social support may reduce the rate of complications. Further research into the factors mediating the relationship of neighborhood income with gender on survival and treatment-related mortality post allo SCT seems necessary.