Impact of Socioeconomic Factors on Access to and Outcomes of Allogeneic Hematopoietic Cell Transplantation (allo-HCT) for Acute Myeloid Leukemia (AML): A Multi-Center Observational Study
Authors: Wuliji Natalie , Gooley Ted , Jones Salene , Gerds Aaron T. , Medeiros Bruno , Shami Paul J. , Galvin John , Adekola Kehinde , Luger Selina , Baer Maria R. , Rizzieri David A. , Wildes Tanya M. , Wang Eunice S. , Sekeres Mikkael A. , Mukherjee Sudipto , Smith Julie C. , Garrison Mitchell A. , Kojouri Kiarash , Appelbaum Jacob S. , Percival Mary-Elizabeth M. , Sandmaier Brenda M. , Appelbaum Frederick R. , Sorror Mohamed 
Published: December 2024

Introduction:
We have previously shown that age, comorbidity burden, cytogenetic risk, and geriatric health significantly impact the likelihood of receiving allo-HCT and mortality among AML patients (pts). Building on these findings, we now examine the role of socioeconomic status (SES) as determined by the areas where participants lived within the same study cohort, focusing on the receipt of allo-HCT and post-transplant mortality.
Methods:
Here we report results of a prospective, multi-center observational study across 13 predominantly academic centers enrolling adult AML pts. We examined the following SES factors as estimated by the zip codes in which pts lived: median household income; % of adults aged ≥25 years with &lt; a high school education or equivalent (i.e., General Education Diploma); % of households below the poverty level; % of households receiving Supplemental Nutrition Assistance Program (SNAP)/food stamps; % of occupied housing units (rented and owner-occupied) where 30% or more of income is spent on housing; % of owner-occupied housing units with a mortgage that have either a second mortgage, home equity loan or both; % of households receiving Supplemental Security Income (SSI, disability); and % of people working for pay who drive to work alone. Fine-Gray regression models were used to evaluate factors influencing the receipt of HCT, where death without HCT was treated as a competing risk. For overall mortality after HCT, Cox regression with left truncation at HCT was employed. All SES factors were modeled as continuous linear variables, with hazard ratio (HR) presented in terms of an increase in income of $25,000 and an increase in % of other factors of 10%. Additionally, each SES model was adjusted for age, Hematopoietic Cell Transplant-specific Comorbidity Index, disease status, European LeukemiaNet risk, Karnofsky Performance Scale, Patient Health Questionnaire-9, Activities of Daily Living, 4-Meter Walk Test, and Functional Assessment of Cancer Therapy.
Results:
In our analysis of 695 AML pts, a multivariable analysis showed a decrease in the likelihood of HCT receipt by 32% as the percentage of residents with less than a high school education in a neighborhood increased by 10% (HR: 0.68; 95% CI, 0.55-0.84, p=0.0005). We also observed a 14% decrease in the likelihood to receive allo-HCT for each 10% increase in households receiving SNAP compared to baseline levels (HR=0.86; 95% CI, 0.74-1.00, p=0.04). On the other hand, increase in the likelihood of HCT receipt was modest (5%) as median area income increased by $25,000 compared to areas with baseline median income (HR: 1.05; 95% CI, 0.94-1.18, p=0.39). There was also a small decrease (15%) in the likelihood of HCT receipt for each 10% increase in percentage of households below the poverty level (HR=0.85; 95% CI, 0.70-1.03, p=0.10) but a larger decrease (34%) for each 10% increase in households receiving SSI (HR=0.66; 95% CI, 0.39-1.11, p=0.11).
There was little evidence of an association between median area income and overall mortality after HCT (HR: 0.97; 95% CI, 0.57-1.66, p=0.92). There was a numerical increased hazard of mortality after HCT as the percentage of residents with less than a high school education in a neighborhood increased by 10%, but the increase was modest (HR: 1.14; 95% CI, 0.66-1.98, p=0.64), little evidence of an increase or decrease in mortality as the percentage of households below the poverty level increased by 10% (HR=0.98; 95% CI, 0.61-1.57, p=0.92), and numerical (but modest) increases in mortality as the percentage of households receiving SNAP increased by 10% (HR=1.10; 95% CI, 0.77-1.57, p=0.60), and as the percentage of households receiving SSI increased by 10% (HR=1.23; 95% CI, 0.73-1.29, p=0.40).
Conclusion:
These findings underscore potential impact of socioeconomic disparities on receipt of HCT in AML pts. Lower educational attainment could be a barrier to receiving HCT. This suggests the primary issue is access to HCT, as SES does not seem to definitively affect post-transplant outcomes among those who receive HCT. This highlights the need for targeted interventions to improve access to HCT for pts from lower socioeconomic backgrounds. Efforts should focus on addressing financial barriers, improving health literacy, and enhancing support systems to ensure equitable access to life-saving treatments. These are some of the key focuses of the ACCESS initiative by the ASTCT and NMDP (Auletta, TCT 2022).