Access to Hematopoietic Stem Cell Transplantation among Pediatric Patients with Acute Lymphoblastic Leukemia: A Population-Based Analysis

Abstract

Access to hematopoietic stem cell transplantation (HSCT) in pediatric acute lymphoblastic leukemia (ALL) primarily depends on disease-related factors but may be influenced by social and economic determinants. We included all children aged < 15 years with newly diagnosed ALL in Canada between 2001 and 2018 using the Cancer in Young People in Canada national registry. We examined factors potentially associated with the likelihood of receiving HSCT using univariate and multivariable logistic regression models. A total of 3992 patients with newly diagnosed ALL were included. Three hundred twenty-five (8.1%) received an HSCT and formed the transplant cohort. In multivariable analysis factors independently associated with an increased odds of receiving HSCT were male sex (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.05 to 1.93), initial WBC 50,000 £ 10 9 /L (OR, 1.58; 95% CI, 1.09 to 2.28), mixed phenotype acute leukemia relative to B-precursor ALL (OR, 34.32; 95% CI, 16.64 to 70.79), T cell relative to B-precursor ALL (OR, 1.77; 95% CI, 1.07 to 2.91), unfavorable relative to standard cytogenetics (OR, 3.96; 95% CI, 2.56 to 6.12), and relapse before HSCT (OR, 32.77; 95%, 23.89 to 44.96). No association was found between race, neighborhood income quintile or region at diagnosis, and receipt of HSCT. Diagnosis at an HSCT treating center (OR, 1.51; 95% CI, 1.09 to 2.09) and residential distance from the ALL treating center (OR, 1.84 for 300 km compared with <100 km; 95% CI, 1.17 to 2.91) were associated with higher odds of receiving HSCT. In a publically funded healthcare system, children with ALL had equitable access to HSCT, which was largely governed by biologic disease-related factors. Patients diagnosed at an HSCT performing center and patients who live farthest away from their treatment center had higher odds of receiving HSCT, although the effect was small, possibly suggesting preferential referral to HSCT for some patients.

Outcomes of Lymphoma Among American Adolescent and Young Adult Patients Varied by Health Insurance—A SEER-based Study

“…Our findings verify the significance of insurance status and suggest that considerable race/ethnicity and SES disparities remain even among those with private insurance. Race/ethnicity bias may affect care use (regardless of insurance condition)53–56 and chronic burden because of bias affects health outcomes 57,58. Extreme racial or ethnic differences for cancers prone to avoidance and therapy indicate that disparities in availability of socioeconomic resources (social capital) may intensify residual racial or ethnic disparities in cancer survival 59.…”

Regional differences in access to hematopoietic stem cell transplantation among pediatric patients with acute myeloid leukemia

“…Similarly, an adult study of lymphoma patients in Nebraska showed that use of HSCT among patients seen at university‐based centers was significantly higher compared with community‐based centers 29 . In our most recent study on children with acute lymphoblastic leukemia, initial diagnosis at an HSCT performing center led to 1.5 times odds of receiving HSCT 17 . We hypothesized that the ease of referral for HSCT in these larger centers contributed to higher rates of HSCT.…”

“…29 In our most recent study on children with acute lymphoblastic leukemia, initial diagnosis at an HSCT performing center led to 1.5 times odds of receiving HSCT. 17 We hypothesized that the ease of referral for HSCT in these larger centers contributed to higher rates of HSCT. In addition, the lack of geographical barriers/distance, since these patients would not need to relocate to another center for HSCT, may also have contributed to this finding.…”

“…Furthermore, few studies have examined access to HSCT within a publically funded health care system. Recently, we reported geographical variability in access to HSCT in Canadian children with acute lymphoblastic leukemia suggesting possible preferential referral patterns 17 …”

“…Recently, we reported geographical variability in access to HSCT in Canadian children with acute lymphoblastic leukemia suggesting possible preferential referral patterns. 17 The Cancer in Young People in Canada (CYP-C) program maintains a national childhood cancer surveillance and research registry that includes population-level data on all new malignant diagnoses treated at the 17 Canadian pediatric tertiary care centers since 2001. Canada has a national publically funded universal health care system but the provision of health services is administered by the individual provinces and territories.…”