Trends in hematopoietic cell transplantation (HCT) in acute myeloid leukemia (AML) from 2004-2019.
Authors: Ravindra Aditya , Loeffler Bradley T. , Joshi Utsav , Bhetuwal Uttam , Sharma Acharya Shiwani , Pyakuryal Avantika , Bhatt Vijaya Raj , Dhakal Prajwal 
Published: June 2024

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Background: Many patients with AML achieve remission after induction chemotherapy, but the relapse rates remain high. For patients with intermediate and adverse-risk AML that have achieved complete remission, HCT often presents the best option for cure. HCT, usually reserved for fit patients with good disease control, comes with different operational, financial, and technical challenges, even in eligible patients. Our study analyzed HCT use in patients with AML from 2004 to 2019 to determine whether the use of HCT has improved in more recent years and identify study subpopulations with an increase in the use of HCT. Methods: Patients with AML from the National Cancer Database were divided into two primary cohorts: patients diagnosed from 2004-2010 and 2011-2019. Logistic regression was used to estimate the effect of patient and disease characteristics on the odds of receiving HCT and evaluate differences between the constructed patient cohorts. Results: Of 78,092 patients with AML, 7204 (9.2%) received HCT. HCT use increased continuously over the years: 6.5% in 2004, 8.4% in 2010, and 10.6% in 2015. There was a slight decrease in HCT from 13.1% in 2018 to 12.2% in 2019. The receipt of HCT declined with increasing age with higher use of HCT in all groups in 2011-2019 compared to 2004-2010: 71-80 years= 2 vs. 0.4 %, 60-70 years= 13 vs 6%, 41-59 years= 18 vs 15%, and 18-40 years = 19 vs 16%. HCT use declined with higher Charlson Deyo Comorbidity Index (CCI) with higher use of HCT in all groups in 2011-2019 compared to 2004-2010: CCI: 2-3= 4 vs 2%, CCI 1= 7% vs 5%, CCI 0= 12% vs 9%. HCT use was higher in patients who traveled longer distances to hospitals with higher HCT use in 2011-2019 compared to 2004-2010: travel distance ≥38.4 miles= 15 vs. 13%, 12-34.7 miles= 12 vs 9%, 5-11.9 miles= 8 vs 5%, and 0-4.9 miles= 5 vs 3%. On multivariable analysis, the odds of receiving HCT increased significantly in 2011-2019 compared to 2004-2010, particularly in older patients, patients with higher CCI, and patients who traveled longer distances for treatment. Black race, lower income, no insurance, and lower educational attainment were associated with a lower likelihood of receiving HCT; however, the odds of receiving HCT did not improve over the two time periods based on these variables. Conclusions: To our knowledge, this is the largest-scale analysis of HCT utilization in patients with AML in the United States. The increase in HCT utilization from 2004-2010 to 2011-2019, particularly in older adults and those with more comorbidities, may reflect improvement in risk-stratification models, better supportive care, and better management of treatment-related toxicity. However, despite a modest increase in HCT use over the years, significant disparities exist based on race, insurance type, income, and education. Innovative strategies are necessary to increase HCT and make it accessible to all patients regardless of socioeconomic and demographic factors.