Impact of Socioeconomic, Demographic and Health System Factors on Therapy in Acute Myeloid Leukemia
Authors: Goyal Gaurav , Nawal Lata , Mosalpuria Kailash , Silberstein Peter T. 
Published: October 2019

Abstract
Introduction
Acute myeloid leukemia (AML) is the most common acute leukemia in adults. Once diagnosed, AML is usually treated aggressively with the goal of improving survival. In this study, we aim to evaluate the factors affecting delivery of treatment in patients with AML.
Methods
This is a retrospective study of patients diagnosed with AML from 2003 to 2013 from the National Cancer Database (NCDB). NCDB consists of demographic variables and survival outcomes of approximately 70% of all new cancer diagnoses in the United States and Puerto Rico. Univariate logistic regression was performed to calculate crude odds ratio for different variables.
Results
A total of 98,293 patients were diagnosed with AML from 2003-2013, of which 24% (23,328) did not receive any systemic therapy (ST). On univariate analysis, the odds of receiving treatment were lower among females (Odds Ratio [OR] =0.97; 0.94-0.99), elderly (OR=0.15; 0.15-0.16), and Medicare patients (OR=0.23; 0.22- 0.23). Patients with one or more comorbidities had lower odds of receiving treatment compared to patients without any comorbidities (OR for 1 comorbidity=0.65; 0.63- 0.67, and OR for ≥ 2 comorbidities=0.42; 0.40-0.44). The odds of receiving ST were lower in community hospitals as compared to academic centers (OR=0.34; 0.32-0.35). African Americans had higher odds of receiving ST compared to Whites (OR=1.20; 1.13- 1.26). The patients belonging to households with higher income (>$49K) had higher odds of receiving ST (OR=1.14; 1.08-1.20). The histologic subtype associated with highest odds of receiving treatment was acute promyelocytic leukemia (OR=2.43; 2.27- 2.59). Compared to the reference period 2003-2006, patients diagnosed with AML during the later time period had higher odds for receiving therapy: 2007-2010 (OR =1.11; 1.08- 1.15), and 2011-2013 (OR=1.27; 1.22- 1.31) respectively (Table 1).
Conclusions
Although the number of people receiving therapy for AML has increased over time, factors like older age, comorbidities, lower household income, having Medicare, and being diagnosed at a community hospital were associated with lesser odds of receiving ST. More studies are needed to assess the impact of these factors on patient survival.
Table 1. Systemic therapy in AML Variable Systemic Therapy (% of total) n = 74965 No Systemic Therapy (% of total) n = 23328 Odds ratio (95% CI) Gender Male 41 13 1.00 Female 35 11 0.97 (0.94, 0.99) Age ≤ 70 y 54 6 1.00 > 70 y 23 17 0.15 (0.15, 0.16) Race White 59 20 1.00 Black 7 2 1.20 (1.13, 1.26) Others 10 2 1.53 (1.45, 1.61) Year of diagnosis 2003-2006 24 8 1.00 2007-2010 27 9 1.11(1.08,1.15) 2011-2013 25 7 1.27 (1.22, 1.31) Insurance Private 32 4 1.00 Medicaid 7 1 1.16 (1.07, 1.26) Medicare 29 17 0.23 (0.22, 0.23) No Insurance 3 1 0.61 (0.55, 0.66) Others 5 1 0.61 (0.57, 0.66) Household income < $28K 7 2 1.00 $28K -$32,999 10 3 1.04 (0.98, 1.11) $33K - $38,999 14 5 1.01 (0.95, 1.08) $39K - $48,999 18 6 1.05 (0.99, 1.11) $49K + 27 8 1.14 (1.08, 1.20) Comorbidity None 58 15 1.00 Only 1 comorbid condition 14 5 0.65 (0.63, 0.67) Two or more comorbid conditions 5 3 0.42 (0.40, 0.44) Histology Acute Myeloid Leukemia (AML) 42 16 1.00 Acute Promyelocytic Leukemia (APL) 8 1 2.43 (2.27, 2.59) Acute Myelomonocytic Leukemia (AMyL) 6 2 1.25 (1.18, 1.32) Acute Myeloid Leukemia with Multilineage Dysplasia (AMLMD) 5 2 1.11 (1.05, 1.18) Acute Myeloid Leukemia with Maturation (AMLM) 4 1 1.56 (1.44, 1.68) Acute Myeloid Leukemia without Maturation (AMLWM) 3 1 2.02 (1.85, 2.21) Acute Myeloid Leukemia, Minimal Differentation 2 1 0.98 (0.91, 1.06) Other Specified Types (OST) 2 1 1.23 (1.11, 1.36) Erythroleukemia 2 1 1.07 (0.97, 1.18) Facility Type (n= 83431) Academic 50 8 1.00 Community 29 13 0.34 (0.32, 0.35) AML: Acute myeloid leukemia

Disclosures
No relevant conflicts of interest to declare.