Socioeconomic position and maintenance therapy in children with acute lymphoblastic leukemia: A national cohort study

Pediatr Blood Cancer. 2022 Jul;69(7):e29508. doi: 10.1002/pbc.29508. Epub 2021 Dec 21.


Background: Socioeconomic differences in survival among children with acute lymphoblastic leukemia (ALL) have been reported in high-income countries and there is an unmet need for strategies to identify vulnerable patient subgroups. Reported differences in survival for children from families with different socioeconomic positions seem to arise when starting maintenance therapy. This could reflect reduced physician's compliance or family adherence to maintenance therapy.

Methods: This nationwide cohort study with extensive monitoring of systemic methotrexate (MTX)/6-mercaptopurine (6MP) dosing and metabolite levels, retrospectively investigated 173 Danish children treated according to The Nordic Society for Pediatric Hematology and Oncology ALL2008 protocol from 2008 to 2016.

Results: Significantly lower prescribed doses of MTX and 6MP were seen in the children in families with short parental education (short vs. medium vs. higher education: mMTX: 13.8, 16.2, and 18.6 mg/m2 /week; p < .01; m6MP: 47.4, 64.9, and 66.1 mg/m2 /day; p = .03) or parents unemployed/not in workforce (unemployed/not in workforce vs. mixed vs. at work: mMTX: 15.0, 19.9, and 17.2 mg/m2 /week; p < .01; m6MP: 54.8, 72.0, and 65.1 mg/m2 /day; p < .01). When assessing family adherence by analyzing MTX and 6MP metabolite levels, including per prescribed dose of MTX and 6MP, we found no significant differences by levels of parental education, affiliation to work market, or income (p > .05 for all comparisons).

Conclusions: These results indicate that inferior physician compliance to protocol recommendations on drug dosage rather than families' adherence to therapy may contribute to the association between socioeconomic position and cure rates in childhood ALL, although precise mechanisms remain to be explored.

Keywords: adherence; childhood leukemia; compliance; maintenance therapy; socioeconomic position.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Disease
  • Antineoplastic Combined Chemotherapy Protocols* / therapeutic use
  • Child
  • Cohort Studies
  • Humans
  • Mercaptopurine
  • Methotrexate / therapeutic use
  • Precursor Cell Lymphoblastic Leukemia-Lymphoma* / drug therapy
  • Retrospective Studies
  • Socioeconomic Factors


  • Mercaptopurine
  • Methotrexate