Socioeconomic Influences on the Treatment and Outcomes of Patients with Acute Myeloid Leukemia: Experience from an Urban Academic Center
Authors: Pan Jonathan , Ghimire Sushil , Halloran Molly , Xu Alexander , Zhan Tingting , Keiffer Gina , Wilde Lindsay , Palmisiano Neil , Kasner Margaret , Binder Adam F. 
Published: November 2020

Introduction
Disparities in age, socioeconomic status, insurance status and race/ethnicity have all been shown to impact the treatment and survival outcomes in patients with acute myeloid leukemia (AML). Database studies have highlighted that elderly patients with AML have worse survival outcomes. There is also evidence that Black and Hispanic patients with AML have an increased risk of death compared with Caucasian patients despite a higher prevalence of favorable cytogenetics and a younger age at diagnosis in those minority groups. We sought to assess the impact of age, race/ethnicity, socioeconomic and insurance status on treatment and survival outcomes in AML patients treated at our institution.
Methods
We performed a retrospective analysis of adult patients with newly diagnosed AML treated between April 2017 and August 2019 at Thomas Jefferson University Hospital. Patient specific variables included demographics, diagnosis, insurance coverage, treatment characteristics and survival outcomes. Socioeconomic status was assessed by matching the patient's residential address to the United States Area-Deprivation Index (ADI). Treatment characteristics included initial treatment type and time to treatment initiation (TTI). Initial treatment type included standard chemoimmunotherapy, clinical trial or novel therapy as defined by the Center for Medicare and Medicaid Services. The primary outcome of initial treatment type and secondary outcomes of TTI, progression free survival (PFS) and overall survival (OS) were analyzed using multivariable bias-reduced logistic regression and multivariable Cox proportional hazards models.
Results
Ninety-six patients were included in the analysis (median age 62; male, n = 48, female, n=48). 46% of patients were in the lower socioeconomic group (ADI = 6-10). 74% of patients were Caucasian, 17% were Black, 9% were Hispanic, and 9% were Asian or other. 44% of patients had private insurance, 44% had Medicare, 7% had Medicaid and 5% were uninsured. 58% of patients received standard chemoimmunotherapy, 35% received novel therapy, and 7% went on clinical trial. Patients who received novel therapy and clinical trial were older (p&lt;0.005). There were no significant differences found between the initial treatment type based on ADI, race/ethnicity or insurance type. There was a longer TTI as ADI increased (p&lt;0.016), in patients who were Black (p&lt; 0.002), Hispanic (p&lt;0.001), those with Medicaid (p&lt;0.007) and those who were older (&lt;0.001). There were no significant differences in PFS and OS between the socioeconomic groups, race/ethnicity or insurance type. Older patients had a worse OS (p&lt;0.001).
Conclusions
In this cohort of newly diagnosed AML patients, age was the only significant predictor of initial treatment type with older patients more likely to receive novel therapy and clinical trial. This is likely due to the poor tolerability of intensive chemotherapy in older patients and multiple recent drug approvals to allow for alternative treatment strategies in this population. ADI, race/ethnicity and insurance type did not affect the choice of initial treatment type. Although there was a treatment delay in patients from lower socioeconomic areas, in patients who were Black or Hispanic, and in patients with Medicaid, this delay did not impact PFS or OS. Our cohort had a small percentage of minority patients which may have been too low to detect a difference in outcomes between race/ethnicity. Further studies assessing a larger cohort are warranted.

Disclosures
Palmisiano: Genentech: Research Funding; AbbVie: Research Funding. Binder:Sanofi: Consultancy; Janssen: Membership on an entity's Board of Directors or advisory committees.