Trend in Systemic Therapy Use in Acute Myeloid Leukemia from 2000 to 2011 Using National Cancer Database
Authors: Khanal Nabin , Upadhyay Smrity , Chaudhary Ranjit Kumar , Bhatt Vijaya R. , Silberstein Peter T. 
Published: October 2019

Abstract
Introduction: Leukemias are the sixth leading cause of death in United States. Acute myeloid leukemia (AML) accounts for approximately 43% of all leukemia related deaths in United states (CA Cancer J Clin 2014;64(1):9-29). AML is an aggressive leukemia with poor prognosis if not treated with chemotherapy. Large randomized clinical trials have clearly demonstrated a significant survival benefit with chemotherapy in young fit patients. The use of chemotherapy may lead to long-term disease control or even cure in some of these patients, particularly the good risk AML. However, chemotherapy regimens are frequently intensive and may be too toxic for older patients. Our aim was to analyze the trend in systemic therapy in AML between academic and non academic centers.
Methods: This is a retrospective study of AML (n=74,746) diagnosed between 2000 and 2011 in the National Cancer Database (NCDB). NCDB contains ~70% of new cancer diagnosis from >1,500 accredited cancer programs in the United States and Puerto Rico. Chi-square test was used to determine any differences in characteristics of patients who did or did not receive systemic therapy and characteristics of patients receiving care in academic and non academic centers were compared.
Results: There were a total of 99,664 cases in our study, consisting predominantly of white (n=35,082, 77%) males (n= 54146, 54%) aged 70 years or above (39%, n= 38,148). Our study demonstrated that 85% of patients received systemic therapy in academic centers compared to 66% patients in non academic center. The use of systemic therapy was significantly lower in Whites/African Americans, patients >60 years, those without insurance or with Medicare, higher Charlson Comorbidity score, poor economic and educational status (table 1).
Conclusions: This is the largest study to evaluate the determinants of systemic therapy use in AML. Overall the use of systemic therapy was lower in non-academic vs. academic centers and in patients >70 years. Additional socioeconomic and educational factors also influenced the use of chemotherapy. Older patients frequently have poor outcomes and may benefit from expertise at academic centers, and enrollment in clinical trials with low-intensity chemotherapy. Understanding the barriers in the use of systemic therapy can optimize cancer care.
Table 1 Patients receiving systemic therapy in AML: Variable Academic center (%) Non academic center (%) Age: <40 96 89 40-49 95 88.5 50-59 93 85.7 60-69 89.5 72.8 >70 67.5 60 Gender : Male 85.3* 67.1 Female 85.4* 65.1 Race: Hispanic 87.3 75.2 White 85.1 65.2 African Americans 83.8 68 Insurance: Private 92.5 81.9 Medicaid 92.4 84.3 Uninsured 86.3 76.7 Medicare 73.1 53.8 Education#: >31% 85.3 65.9 12-30.9% 85.2 65.5 <12% 85 67.1 Charlson Comorbidity Score 0 87.8 69.7 1 82.2 61.3 2 or more 73.8 51.8 Income <28000 83 63.9 >28000 85.4 66.2
*: p-value >0.01, p-value <0.01 for all comparison except stated.
#:aggregate percent of individuals without a high school degree for the zip code of the patient recorded at the time of diagnosis

Disclosures
No relevant conflicts of interest to declare.