Distance to Treatment Center Impacts Survival in Children and Young Adults With Acute Lymphoblastic Leukemia

Children and young adults with acute lymphoblastic leukemia (ALL) who live more than 50 miles away from a treatment center face inferior survival outcomes, according to a recent study conducted at Cleveland Clinic Children’s.

“There have been great advances in treatment for leukemia; however, outcomes remain variable,” says Rabi Hanna, MD, Chair of the Department of Pediatric Hematology, Oncology and Bone and Marrow Transplantation at Cleveland Clinic Children’s and co-author of the study. “We embarked upon this analysis in order to identify variables that may impact outcomes, looking for ways we might improve the care and outcomes of these young patients.”

Variables associated with outcomes in ALL and AML

Researchers investigated possible associations with outcomes as related to variables such as time to treatment, treatment at a National Cancer Institute-designated cancer center, Charlson-Deyo score, age, race, insurance status and community income level among children, and adolescent and young adult (AYA) patients with ALL (N = 22,683) and acute myeloid leukemia (AML; N = 12,301) in the National Cancer Database (NCDB).

For ALL, race, insurance, community median income and living more than 50 miles from a treatment center were associated with survival. Specifically, patients who identified as Black, Hispanic/Latino or Native American had inferior survival outcomes compared with those who identified as white. Patients with government insurance or no insurance at the time of diagnosis had inferior survival compared with patients who had private insurance. Additionally, patients living in communities with a median income of ≥ $63,000 had superior outcomes when compared with patients living in communities with lower median incomes.

Among the AML cohort, distance to a treatment center was not associated with survival. Similar to the ALL model, insurance and community median income level were associated with survival. Racial disparities were prevalent in AML as well, as individuals who identified as Black had inferior survival compared with those who identified as white. However, no difference was seen for those who identified as Asian, Hispanic/Latino or Native American compared with patients who identified as white.

Image reused with permission. Originally published in: Rotz SJ, Wei W, Thomas SM, Hanna R. Distance to treatment center is associated with survival in children and young adults with acute lymphoblastic leukemia. Cancer. 2020;0:1-9.

Understanding patients, not just their diseases

“With more than 20% of children and young adults with ALL living more than 50 miles from a treatment center, this is a significant proportion of patients,” says co-author and pediatric hematologist-oncologist Seth Rotz, MD, of Cleveland Clinic Children’s. “Our findings underscore the importance of understanding not just the diseases of our patients, but our patients themselves. Where do they live? How far are they from the nearest pharmacy? From the nearest Emergency Department? Do they have reliable transportation and high-speed internet access? All these variables can impact the continuity and quality of care a child receives.”

“This study gives me a lot of hope,” Dr. Hanna says, “as at least part of the association with distance from treatment centers can be mitigated. Every patient who receives care for pediatric cancer at Cleveland Clinic Children’s receives a comprehensive social work consultation within 30 days of diagnosis. For those patients who live far from us, we work with local agencies to offer local accommodation for families during intense periods of treatment. We partner with transportation services to arrange for rides to clinic if needed. Importantly, we offer virtual visits when possible to answer any questions along the way and ensure adherence to treatment.”