Access Barriers to Transplant Affect Outcomes in AML

Socioeconomic disparities act as barriers to receiving allogeneic hematopoietic cell transplantation (allo-HCT) among people with acute myeloid leukemia (AML), Cleveland Clinic researchers have found. The study found these disparities do not affect outcomes among those who do receive transplants.

“We looked at a large database with collaborating institutions, and found that lower income and education and where you live predicted whether or not you would get a transplant for your disease. On the other hand, while there was a trend toward worse survival after a transplant based on all those factors, it wasn’t statistically significant,” says study author Aaron T. Gerds, MD, MS, Assistant Professor of Medicine in the Department of Hematology and Medical Oncology at Cleveland Clinic Cancer Institute.

Insurance plans typically cover the transplants, but numerous other socioeconomic factors, including high co-pays, distance to the transplant center and the need for full-time caregiving for at least three months after transplantation, present access barriers.

Clinicians should be aware of these barriers and do what they can to help patients with the follow-through, Gerds advises. Patients should be referred for transplant as early as possible. In addition, patient assistance programs such as those run by the Pan Foundation and the Leukemia and Lymphoma Society are in place to help those who lack resources or support.

Socioeconomics affect receipt of HCT, but not survival after.

The new findings were presented at the 2024 American Society of Hematology meeting by study co-investigator Natalie Wuliji, DO of the Fred Hutchinson Cancer Center in Seattle. The study builds on previous data (Blood. 2023 Jan 19;141(3):295-308. doi: 10.1182/blood.2022016916 PMID: 36260765; Blood. 2021 Aug 5;138(5):387-400. doi: 10.1182/blood.2020008812. PMID: 34351368) from the same 13-center group, showing that age, comorbidity burden, cytogenetic risk and geriatric health significantly impact the likelihood of receiving allo-HCT as well as mortality among AML patients.

In the new prospective observational study, the researchers examined the role of a variety of factors associated with socioeconomic status in predicting receipt of allo-HCT and post-transplant mortality among 695 adult AML patients.
In multivariable analysis, there was a 32% decreased likelihood of receiving HCT with every 10% increase in the proportion of residents with less than a high school education in the person’s residential neighborhood, a highly significant finding (p=0.0005). “I expected to see a difference, but I didn't expect it to be this big,” Dr. Gerds notes.

In addition, there was a 14% decrease in the likelihood of HCT receipt with each 10% increase in households receiving Supplemental Nutrition Assistance Program (SNAP, i.e., food stamps) This finding was also significant (p=0.04).
Other trends regarding HCT receipt that didn’t quite achieve statistical significance were an increased likelihood as median area income rose by $25,000 compared with areas with baseline median income (p=0.39), decreased likelihood for each 10% increase in percentage household below the poverty level (p=0.10), and a 34% decreased likelihood for each 10% increase in households receiving Supplemental Security Income (p=0.11).

On the other hand, for those who did undergo HCT, there was no significant influence on mortality of socioeconomic factors, including median area income (p=0.92), 10% increase in percentage of residents with less than a high school education (p=0.64), 10% increase in percentage of households below the poverty level (p=0.92) and 10% increases in household receiving SNAP (p=0.60) or SSI (p=0.40).

“At Cleveland Clinic, the hematologic and malignancy departments work closely with the transplant team, in collaboration with patients,” Gerds says. “When a patient is admitted to our hospital with a new diagnosis of acute leukemia, part of the admitting order set is a referral to transplant. Everybody gets plugged in right away, so if transplant is indicated and it's a suitable time to proceed, we can do so in a very timely fashion.”