Trends and Disparities in Acute Lymphoblastic Leukemia-Related Mortality in the United States from 1999 to 2020: Insights from the CDC Wonder Database
Authors: Shahzad Moazzam , Ahmad Eeman , Ahmed Shahzaib , Akram Umar , Ahmad Shoaib , Amin Muhammad Kashif , Tuz Zahra Fatima , Mushtaq Muhammad Umair , Jaglal Michael V. 
Published: December 2024

Introduction
Acute lymphoblastic leukemia (ALL) has a bimodal distribution. The risk of developing ALL is higher in pediatric populations under 5 years, which declines until the mid-twenties, and then rises again after the fifties. However, the mortality is higher in the adult population compared to pediatrics. Therefore, it is important to identify and analyze trends in deaths related to ALL.
Methods
Age-adjusted mortality rates (AAMR) per 100,000 population from 1999 to 2020 were extracted from the CDC Wide-ranging ONline Data for Epidemiologic Research (WONDER) database. ICD-10 code C91.0 was used to assign ALL as the contributing cause of death. AAMRs were stratified by year, gender, race, and geographical distribution. Annual percentage change (APC) in AAMR was calculated via Joinpoint regression using the Joinpoint Regression Program (V 5.1.0, National Cancer Institute).
Results
A total of 35,056 ALL-related deaths occurred from 1999 to 2020. The AAMR decreased from 1999 to 2020 (APC: -0.65). The AAMR remained higher in men (overall AAMR: 0.59) than in women (overall AAMR: 0.43) throughout the study period, and the AAMRs for both decreased (APC men: -0.75; women: -0.56). Upon stratification by race, several data points for non-Hispanic (NH) American Indian or Alaska Natives were found to be unreliable. The highest AAMR was observed in Hispanics or Latinos (0.75), although this remained largely unvaried (APC: -0.11). The AAMR for NH Whites (0.47) was higher than that of NH Black or African Americans (0.37) and decreased for both from 1999 to 2020 (APC NH Whites: -1.04; NH Black or African Americans: -0.86). NH Asian or Pacific Islanders exhibited the lowest overall AAMR (0.35), with the AAMR decreasing from 1999 to 2018 (APC: -0.64), before a steeper decrease was observed from 2018 to 2020 (APC: -16.64). The West exhibited the highest AAMR (0.59), followed by the South (0.49), the Midwest (0.47) and the Northeast (0.45). However, some interesting trends were observed. The AAMRs declined in the Northeast and the West from 1999 to 2020 and decreased in the South from 1999 to 2014 (APC: -1.22) before increasing until 2018 (APC: 4.77). Subsequently, a sharp decrease was observed until 2020 (APC: -8.82). The AAMR in the Midwest also decreased from 1999 to 2011 (APC: -1.84) before increasing until 2020 (APC: 0.83). Upon stratification by urbanization, we identified a higher overall AAMR in rural areas (0.52) compared to urban areas (0.48). Joinpoint regression revealed a decrease in the AAMR for urban areas from 1999 to 2020 (APC: -0.60), whereas the AAMR for rural areas was observed to decrease from 1999 to 2011 (APC: -1.94) before increasing until 2020 (APC: 1.05). The highest AAMR was observed in California (0.64), Arizona (0.59), Texas (0.59), and Oklahoma (0.58), whereas the lowest was observed in Utah (0.36), Massachusetts (0.39), Louisiana (0.40), and the District of Columbia (0.40).
Conclusion
Overall, a decrease in ALL-related mortality was observed from 1999 to 2020. However, disparities were observed in ALL-related mortality trends across gender, race, census regions, and urbanization. Targeted interventions, including early screening and detection, must be initiated to combat such variations in mortality.