Impact of area deprivation index on clinical outcomes of adults with acute myeloid leukemia at a rural academic medical center.
Authors: Edgren Jordan L. , Ephraim Adam , Palmer John P. , Kazemi Mohadeseh , MacKenzie Todd , Lansigan Frederick , Pirruccello Jonathan P. , Pan Liying , Barrett-Campbell Odeth , Yerrabothala Swaroopa 
Published: June 2023

e18615

Background: Living in a disadvantaged neighborhood may lead to survival disparities amongst patients with acute myeloid leukemia (AML). The Area Deprivation Index (ADI) is a measure of socioeconomic disadvantage by decile used to find discrepancies in healthcare outcomes. Increasing ADI negatively impacts ovarian cancer survival, with each decile increase in state or national ADI corresponding with a 9-10% greater risk of death (Hufnagel D et al., Cancer Epidemiology 2021). Higher ADI was correlated with decreased rates of adjuvant therapy for localized pancreatic cancer (Mora et al., American Journal of Surgery 2021). There are no American studies on ADI and AML. This study aims to identify the impact of socioeconomic disadvantage on survival outcomes for patients with AML in a rural population. Methods: A retrospective review of 180 adults with AML treated at Dartmouth Hitchcock Medical Center (DHMC) between 1/1/2010 - 12/31/2020. Patients with APML, primary treatment outside of DHMC, and those who opted for comfort measures only at diagnosis were excluded. Demographic data, including cytogenetics, treatment type, response to treatment, and survival at one year were recorded. Addresses from the medical record were used to determine state-level ADI using the University of Wisconsin Neighborhood Atlas. Results: Eighty-nine patients were included (64% male; 93% White). Median age was 65 years. Fifty-one patients (57%) had high risk disease, 31 intermediate risk (35%), 5 favorable risk (6%), and unknown risk for 2 (2%). Sixty-two patients (70%) received intensive chemotherapy [7+3] while 27 (30%) received less intensive therapy [hypomethylating therapy]. Twenty-six patients (29%) underwent transplantation. ADI decile was not associated with survival (p = 0.62). Furthermore, when ADI was divided into three groups (deciles 1-3, 4-6, 7-10) there was no difference in survival (p = 0.345). There was no effect of travel distance to DHMC [median 81 minutes] on OS (p = 0.619). There was a significant difference in survival outcomes between the two treatment types (p = 0.001), with median 25.7 vs. 7.1 months in the intensive vs. less intensive groups. This survival advantage was seen on multivariate analysis (p = 0.03). Females had better OS compared to males (p = 0.02) and older age was a negative predictor of outcome (p = 0.007). In those who achieved remission with induction, transplant led to improved survival (p = 0.04). Conclusions: There was no significant difference in treatment outcomes based on ADI, potentially due to equitable quality of care delivered regardless of socioeconomic disparities. This may be due to strong nurse navigation, social work support, specialists from the primary site who provide care in the community, and access to transplantation. Future studies to delineate the impact of various interventions for those with high ADI may be beneficial in treatment planning.