Sociodemographic disparities in chemotherapy and hematopoietic cell transplantation utilization among adult acute lymphoblastic and acute myeloid leukemia patients

PLoS One. 2017 Apr 6;12(4):e0174760. doi: 10.1371/journal.pone.0174760. eCollection 2017.


Introduction: Identifying sociodemographic disparities in chemotherapy and hematopoietic cell transplantation (HCT) utilization for acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) may improve survival for underserved populations. In this study, we incorporate neighborhood socioeconomic status (nSES), marital status, and distance from transplant center with previously studied factors to provide a comprehensive analysis of sociodemographic factors influencing treatments for ALL and AML.

Methods: Using the California Cancer Registry, we performed a retrospective, population-based study of patients ≥15 years old with ALL (n = 3,221) or AML (n = 10,029) from 2003 through 2012. The effect of age, sex, race/ethnicity, marital status, nSES, and distance from nearest transplant center on receiving no treatment, chemotherapy alone, or chemotherapy then HCT was analyzed.

Results: No treatment, chemotherapy alone, or chemotherapy then HCT were received by 11%, 75%, and 14% of ALL patients and 36%, 53%, and 11% of AML patients, respectively. For ALL patients ≥60 years old, HCT utilization increased from 5% in 2005 to 9% in 2012 (p = 0.03). For AML patients ≥60 years old, chemotherapy utilization increased from 39% to 58% (p<0.001) and HCT utilization from 5% to 9% from 2005 to 2012 (p<0.001). Covariate-adjusted analysis revealed decreasing relative risk (RR) of chemotherapy with increasing age for both ALL and AML (trend p <0.001). Relative to non-Hispanic whites, lower HCT utilization occurred in Hispanic [ALL, RR = 0.80 (95% CI = 0.65-0.98); AML, RR = 0.86 (95% CI = 0.75-0.99)] and non-Hispanic black patients [ALL, RR = 0.40 (95% CI = 0.18-0.89); AML, RR = 0.60 (95% CI = 0.44-0.83)]. Compared to married patients, never married patients had a lower RR of receiving chemotherapy [ALL, RR = 0.96 (95% CI = 0.92-0.99); AML, RR = 0.94 (95% CI = 0.90-0.98)] or HCT [ALL, RR = 0.58 (95% CI = 0.47-0.71); AML, RR = 0.80 (95% CI = 0.70-0.90)]. Lower nSES quintiles predicted lower chemotherapy and HCT utilization for both ALL and AML (trend p <0.001).

Conclusions: Older age, lower nSES, and being unmarried predicted lower utilization of chemotherapy and HCT among ALL and AML patients whereas having Hispanic or black race/ethnicity predicted lower rates of HCT. Addressing these disparities may increase utilization of curative therapies in underserved acute leukemia populations.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Antineoplastic Agents / therapeutic use*
  • Combined Modality Therapy
  • Demography*
  • Female
  • Hematopoietic Stem Cell Transplantation*
  • Humans
  • Leukemia, Myeloid, Acute / drug therapy
  • Leukemia, Myeloid, Acute / therapy*
  • Male
  • Middle Aged
  • Precursor Cell Lymphoblastic Leukemia-Lymphoma / drug therapy
  • Precursor Cell Lymphoblastic Leukemia-Lymphoma / therapy*
  • Social Class*
  • Young Adult


  • Antineoplastic Agents

Grant support

This study was supported, in part, by contracts N01-PC-35136, N01-PC-35139 and N02-PC-15105 from the National Cancer Institute and the Surveillance Epidemiology and End Results (SEER) program; contract U58DP000807-01 from the Centers for Disease Control and Prevention and the National Program for Cancer Registries; and the California Department of Public Health Cancer Surveillance Branch. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.