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Ballen K, Wang T, He N, Knight JM, Hong S, Frangoul H, Verdonck LF, Steinberg A, Diaz MA, LeMaistre CF, Badawy SM, Pu JJ, Hashem H, Savani B, Sharma A, Lazarus HM, Abid MB, Tay J, Rangarajan HG, Kindwall-Keller T, Freytes CO, Beitinjaneh A, Winestone LE, Gergis U, Farhadfar N, Bhatt NS, Schears RM, Gómez-Almaguer D, Aljurf M, Agrawal V, Kuwatsuka Y, Seo S, Marks DI, Lehmann L, Wood WA, Hashmi S, Saber W. Impact of Race and Ethnicity on Outcomes After Umbilical Cord Blood Transplantation. Transplant Cell Ther 2024:S2666-6367(24)00533-5. [PMID: 39033978 DOI: 10.1016/j.jtct.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/19/2024] [Accepted: 07/08/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Umbilical cord blood transplant (UCBT) improves access to transplant for patients lacking a fully matched donor. Previous Center for International Blood and Marrow Transplant Research (CIBMTR) showed that Black patients had a lower overall survival (OS) than White patients following single UCBT. The current study draws on a larger modern cohort and compares outcomes among White, Latinx, Black, and Asian patients. OBJECTIVE To compare outcomes by social determinants of health. STUDY DESIGN We designed a retrospective study using CIBMTR data. US patients were between ages 1 and 80; 983 received single and 1529 double UCBT as reported to CIBMTR, following either a myeloablative (N = 1752) or reduced intensity conditioning (N = 759) for acute myeloid leukemia, acute lymphoid leukemia, or myelodysplasia. The primary outcome was 2-year OS. Secondary outcomes included disease free survival, transplant related mortality (TRM), acute and chronic graft vs host disease (GVHD), and GVHD free, relapse free survival (GRFS). RESULTS For 1705 adults, in univariate analysis, 2-year OS was 41.5% (99% CI, 37.6 to 45.3) for Whites, 36.1% (99% CI, 28.2 to 44.5) for Latinx, 45.8% (99% CI, 36.7 to 55.1) for Blacks, and 44.5% (99% CI, 33.6 to 55.6) for Asians. In multivariate analysis of adults, Latinx patients had inferior OS compared to black patients (p = .0005, HR 1.45, 99% CI 1.18 to 1.79). OS improved over time for all racial/ethnic groups. GVHD rates were comparable among the different racial/ethnic groups. In the 807 children, the 2-year OS in univariate analysis was 66.1% (99% CI, 59.7 to 72.2) for Whites, 57.1% (99%CI, 49 to 64.9) for Latinx, 46.8% (99%CI, 35.3 to 58.4) for Blacks, and 53.8% (99%CI, 32.7 to 74.2) for Asians. In multivariate analysis, no difference in OS was observed among racial/ethnic groups (p = .051). Grade III/IV acute GVHD was higher in Blacks compared with Whites (p = .0016, HR 2.25, 99% CI 1.36 to 3.74) and Latinx (p = .0016, HR 2.17, 99% CI 1.43 to 3.30). There was no survival advantage to receiving a UCB unit from a donor of similar race and ethnicity, for any racial/ethnic groups, for both children and adults. Black and Latinx adult patients were more likely to live in areas defined as high poverty. Patients from high poverty level areas had worse OS (p = .03), due to a higher rate of TRM (p=0.04). Educational level, and type of insurance did not impact overall survival, GVHD, TRM or other transplant outcomes. Children from areas with a higher poverty level had higher TRM, regardless of race and ethnicity (p = .02). Public health insurance, such as Medicaid, was also associated with a higher TRM (p = .02). However, poverty did not impact pediatric OS, DFS, or other post-transplant outcomes. CONCLUSIONS OS for UCBT has improved over time. In adults, OS is comparable among Whites, Blacks, and Asians and lower for Latinx patients. In children, OS is comparable among Whites, Blacks, Latinx, and Asians, but Grade III/IV acute GVHD was higher in Black patients. There was no survival benefit to matching UCB unit and patient by race and ethnicity for adults and children.
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Affiliation(s)
- Karen Ballen
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, Virginia.
| | - Tao Wang
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin; CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Naya He
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer M Knight
- Section of BMT & Cellular Therapies; Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sanghee Hong
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Haydar Frangoul
- The Children's Hospital at TriStar Centennial Medical Center, Nashville, Tennessee; Sarah Cannon Research Institute, Nashville, Tennessee
| | - Leo F Verdonck
- Department of Hematology/Oncology, Isala Clinic, Zwolle, The Netherlands
| | | | - Miguel A Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
| | | | - Sherif M Badawy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Hematology, Oncology, and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jeffrey J Pu
- VA Boston Medical Center/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - Bipin Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Muhammad Bilal Abid
- Divisions of Hematology/Oncology & Infectious Diseases, BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason Tay
- Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Hemalatha G Rangarajan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Nationwide Children's hospital, Columbus, Ohio
| | | | - Cesar O Freytes
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Lena E Winestone
- Division of Allergy, Immunology, and Blood & Marrow Transplant, University of California San Francisco Benioff Children's Hospitals, San Francisco, California
| | - Usama Gergis
- Department of Medical Oncology, Division of Hematological Malignancies, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nosha Farhadfar
- Sarah Cannon Transplant & Cellular Program at Methodist Hospital, San Antonio, Texas
| | - Neel S Bhatt
- University of Washington School of Medicine, Department of Pediatrics, Division of Hematology/Oncology and Bone Marrow Transplant, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Raquel M Schears
- University of Central Florida, Department of Emergency Medicine, Orlando, Florida
| | - David Gómez-Almaguer
- Hospital Universitario Dr. José E. González, Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Vaibhav Agrawal
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Yachiyo Kuwatsuka
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - David I Marks
- Bristol Hematology and Oncology Unit, University of Bristol, Bristol, UK
| | - Leslie Lehmann
- Dana Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - William A Wood
- Division of Hematology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Shahrukh Hashmi
- Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE; Mayo Clinic Cancer Center, Mayo Clinic, Rochester, Minnesota; College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, UAE
| | - Wael Saber
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Khera N, Ailawadhi S, Brazauskas R, Patel J, Jacobs B, Ustun C, Ballen K, Abid MB, Diaz Perez MA, Al-Homsi AS, Hashem H, Hong S, Munker R, Schears RM, Lazarus HM, Ciurea S, Badawy SM, Savani BN, Wirk B, LeMaistre CF, Bhatt NS, Beitinjaneh A, Aljurf M, Sharma A, Cerny J, Knight JM, Kelkar AH, Yared JA, Kindwall-Keller T, Winestone LE, Steinberg A, Arnold SD, Seo S, Preussler JM, Hossain NM, Fingrut WB, Agrawal V, Hashmi S, Lehmann LE, Wood WA, Rangarajan HG, Saber W, Hahn T. Trends in volumes and survival after hematopoietic cell transplantation in racial/ethnic minorities. Blood Adv 2024; 8:3497-3506. [PMID: 38661372 PMCID: PMC11260842 DOI: 10.1182/bloodadvances.2023012469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/26/2024] Open
Abstract
ABSTRACT There has been an increase in volume as well as an improvement in overall survival (OS) after hematopoietic cell transplantation (HCT) for hematologic disorders. It is unknown if these changes have affected racial/ethnic minorities equally. In this observational study from the Center for International Blood and Marrow Transplant Research of 79 904 autologous (auto) and 65 662 allogeneic (allo) HCTs, we examined the volume and rates of change of autoHCT and alloHCT over time and trends in OS in 4 racial/ethnic groups: non-Hispanic Whites (NHWs), non-Hispanic African Americans (NHAAs), and Hispanics across 5 2-year cohorts from 2009 to 2018. Rates of change were compared using Poisson model. Adjusted and unadjusted Cox proportional hazards models examined trends in mortality in the 4 racial/ethnic groups over 5 study time periods. The rates of increase in volume were significantly higher for Hispanics and NHAAs vs NHW for both autoHCT and alloHCT. Adjusted overall mortality after autoHCT was comparable across all racial/ethnic groups. NHAA adults (hazard ratio [HR] 1.13; 95% confidence interval [CI] 1.04-1.22; P = .004) and pediatric patients (HR 1.62; 95% CI 1.3-2.03; P < .001) had a higher risk of mortality after alloHCT than NHWs. Improvement in OS over time was seen in all 4 groups after both autoHCT and alloHCT. Our study shows the rate of change for the use of autoHCT and alloHCT is higher in NHAAs and Hispanics than in NHWs. Survival after autoHCT and alloHCT improved over time; however, NHAAs have worse OS after alloHCT, which has persisted. Continued efforts are needed to mitigate disparities for patients requiring alloHCT.
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Affiliation(s)
- Nandita Khera
- Department of Hematology/Oncology, Mayo Clinic, Phoenix, AZ
| | | | - Ruta Brazauskas
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jinalben Patel
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Benjamin Jacobs
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Celalettin Ustun
- Division of Hematology, Oncology, and Cell Therapy, Rush University, Chicago, IL
| | - Karen Ballen
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, VA
| | - Muhammad Bilal Abid
- Divisions of Hematology/Oncology & Infectious Diseases, BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, WI
| | - Miguel Angel Diaz Perez
- Department of Hematology/Oncology, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
| | - A. Samer Al-Homsi
- New York University Grossman School of Medicine, Langone Health, New York, NY
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - Sanghee Hong
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | - Raquel M. Schears
- University of Central Florida, Department of Emergency Medicine, Orlando, FL
| | - Hillard M. Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Stefan Ciurea
- Hematopoietic Stem Cell Transplantation and Cellular Therapy Program, University of California, Irvine, Orange, CA
| | - Sherif M. Badawy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Hematology, Oncology, and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Bipin N. Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, PA
| | | | - Neel S. Bhatt
- Division of Hematology/Oncology and Bone Marrow Transplant, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jan Cerny
- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Chan Medical School and Medical Center, Worcester, MA
| | - Jennifer M. Knight
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI
| | - Amar H. Kelkar
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Jean A. Yared
- Transplantation & Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, Baltimore, MD
| | | | - Lena E. Winestone
- Division of Allergy, Immunology, and Blood & Marrow Transplant, University of California, San Francisco Benioff Children’s Hospitals, San Francisco, CA
| | | | - Staci D. Arnold
- Aflac Cancer and Blood Disorder Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Jaime M. Preussler
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, MN
| | - Nasheed M. Hossain
- Divisions of Hematology/Oncology, Department of Medicine, Cell Therapy and Transplantation Program, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Warren B. Fingrut
- Harvard T.H. Chan School of Public Health, Boston, MA
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vaibhav Agrawal
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Shahrukh Hashmi
- Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
- Mayo Clinic Cancer Center, Mayo Clinic, Rochester, MN
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, UAE
| | - Leslie E. Lehmann
- Dana Farber Boston Children’s Cancer and Blood Disorder Center, Boston, MA
| | - William A. Wood
- Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hemalatha G. Rangarajan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Nationwide Children’s Hospital, Columbus, OH
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Theresa Hahn
- Department of Cancer Prevention & Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY
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3
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Garcia L, Feinglass J, Marfatia H, Adekola K, Moreira J. Evaluating Socioeconomic, Racial, and Ethnic Disparities in Survival Among Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplants. J Racial Ethn Health Disparities 2024; 11:1330-1338. [PMID: 37126157 PMCID: PMC10618412 DOI: 10.1007/s40615-023-01611-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/02/2023]
Abstract
This study was undertaken to monitor potential disparities in survival after allogeneic hematopoietic stem cell transplantation (HSCT) with the aim of optimizing access and outcomes for minority and low-income patients. We analyzed 463 patients transplanted over a 72-month study period with a median 19-month follow-up, focused on differences by individual patient race/ethnicity and patients' household income derived from geocoded addresses at the census block group level. Patient sociodemographic and clinical characteristics were abstracted from electronic health records and our HSCT registry, including disease category and status, donor age, transplant type, and conditioning. Approximately, 15% of HSCT patients were non-Hispanic Black or Hispanic with a similar proportion from block groups below the median metropolitan Index of Concentration at the Extremes income score. The overall survival probability was 61.8% at 36 months. Non-Hispanic white (63.6%) and especially Hispanic patients (49.2%) had lower survival probabilities at 36 months than non-Hispanic Black patients (75.6%, p = 0.04). There were no other patient characteristics significantly associated with survival at the p < 0.01 level. The lack of significant differences likely reflects the careful selection of patients for transplants. However, the proportion of minority and low-income patients relative to expected disease prevalence in our area population raises important considerations about which patients successfully make it to transplant. We conclude with recommendations to increase the diversity of patients who receive HSCT by reviewing potential barriers in the transplant referral and selection process and advocating for needed psychosocial and community resources.
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Affiliation(s)
- Lawrence Garcia
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joe Feinglass
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, 750 Lakeshore Dr., 10th Floor, Chicago, IL, 60611, USA.
| | - Hardik Marfatia
- Economics Department, Northeastern Illinois University, Chicago, IL, USA
| | - Kehinde Adekola
- Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jonathan Moreira
- Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Chen X, Shukla M, Saint Fleur-Lominy S. Disparity in hematological malignancies: From patients to health care professionals. Blood Rev 2024; 65:101169. [PMID: 38220565 DOI: 10.1016/j.blre.2024.101169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/16/2024]
Abstract
In the recent few decades, outcomes in patients diagnosed with hematological malignancies have been steadily improving. However, the improved prognosis does not distribute equally among patients from different backgrounds. Besides cancer biology, demographic and geographic disparities have been found to impact overall survival significantly. Specifically, patients from underrepresented minorities including Black and Hispanics, and those with uninsured status, having low socioeconomic status, or from rural areas have had worse outcomes historically, which is uniformly true across all major subtypes of hematological malignancies. Similar discrepancy is also seen in the health care professional field, where a gender gap and a disproportionally low representation of health care providers from underrepresented minorities have been long existing. Thus, a comprehensive strategy to mitigate disparity in the health care system is needed to achieve equity in health care.
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Affiliation(s)
- Xiaoyi Chen
- Department of Medicine, Division of Hematology and Medical Oncology, New York University, Grossman School of Medicine, NY, New York, USA.
| | - Mihir Shukla
- Department of Medicine, Division of Hematology and Medical Oncology, New York University, Grossman School of Medicine, NY, New York, USA.
| | - Shella Saint Fleur-Lominy
- Department of Medicine, Division of Hematology and Medical Oncology, New York University, Grossman School of Medicine, NY, New York, USA; Perlmutter Cancer Center, NYU Langone Health, NY, New York, USA.
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Khera N, Edwards ML, Song Y, Sun R, Manghani R, Shin H, Simantov R, Signorovitch J, Sivaraman S, Gergis U. Projected Impact of Omidubicel-onlv on Racial/Ethnic Disparities in Allogeneic Hematopoietic Cell Transplantation (Allo-HCT) Outcomes in Hematologic Malignancies. Adv Ther 2024; 41:1637-1651. [PMID: 38427220 PMCID: PMC10960759 DOI: 10.1007/s12325-023-02771-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/14/2023] [Indexed: 03/02/2024]
Abstract
INTRODUCTION In a phase III clinical trial (NCT02730299), omidubicel-onlv, a nicotinamide-modified allogeneic hematopoietic progenitor cell therapy, showed rapid hematopoietic and immune recovery compared with standard umbilical cord blood (UCB) transplant across all racial/ethnic groups. METHODS A decision-tree model was used to project the effect of omidubicel-onlv availability on addressing health disparities in allogeneic hematopoietic cell transplantation (allo-HCT) access and outcomes for patients with hematologic malignancies. The model used a hypothetical population of 10,000 allo-HCT-eligible US adults, for whom matched related donors were not available. Patients received matched or mismatched unrelated donor, haploidentical, UCB transplant, or no transplant. Scenarios with omidubicel-onlv use of 0% (status quo), 10%, 15%, 20%, and 30% were modeled on the basis of proportional reductions in other allo-HCT sources or no transplant by racial/ethnic group. RESULTS Increased omidubicel-onlv use was associated with a higher proportion of patients undergoing allo-HCT, decreased time to allo-HCT, decreased 1-year non-relapse mortality, and increased 1-year overall survival, particularly among racial minorities. In the scenario modeling 20% omidubicel-onlv use, the proportion of Black patients receiving allo-HCT increased by 129%; increases were also observed in Asian (64%), Hispanic (45%), and other (42%) patient groups. Modeled time to allo-HCT improved among transplanted patients (23%) from 11.4 weeks to 8.8 weeks. One-year OS in the overall population increased by 3%, with improvements ranging from 3% for White patients to 5% for Black patients. CONCLUSION This study demonstrates that broad access to omidubicel-onlv could increase access to allo-HCT and improve outcomes for patients, with the greatest benefits seen among racial/ethnic minority groups.
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Affiliation(s)
- Nandita Khera
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | | | - Yan Song
- Analysis Group Inc., Boston, MA, USA
| | | | | | | | | | | | | | - Usama Gergis
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut St, Ste 308, Philadelphia, PA, 19107, USA.
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Ashok Kumar P, Ghimire K, Haroun E, Kassab J, Saba L, Gentile T, Dutta D, Lim SH. Utilization and outcome disparities in allogeneic hematopoietic stem cell transplant in the United States. Eur J Haematol 2024; 112:328-338. [PMID: 37899652 DOI: 10.1111/ejh.14129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/31/2023]
Abstract
Allogeneic hematopoietic stem cell transplant (allo-HSCT) is increasingly being used in the United States (US) and across the world as a curative therapeutic option for patients with certain high-risk hematologic malignancies and non-malignant diseases. However, racial and ethnic disparities in utilization of the procedure and in outcome following transplant remain major problems. Racial and ethnic minority patients are consistently under-represented in the proportion of patients who undergo allo-HSCT in the US. The transplant outcomes in these patients are also inferior. The interrelated driving forces responsible for the differences in the utilization and transplant outcome of the medical intervention are socioeconomic status, complexity of the procedure, geographical barriers, and the results of differences in the genetics and comorbidities across different races. Bridging the disparity gaps is important not only to provide equity and inclusion in the utilization of this potentially life-saving procedure but also in ensuring that minority groups are well represented for research studies about allo-HSCT. This is required to determine interventions that may be more efficacious in particular racial and ethnic groups. Various strategies at the Federal, State, and Program levels have been designed to bridge the disparity gaps with varying successes. In this review paper, we will examine the disparities and discuss the strategies currently available to address the utilization and outcome gaps between patients of different races in the US.
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Affiliation(s)
- Prashanth Ashok Kumar
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Krishna Ghimire
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Elio Haroun
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Joseph Kassab
- Department of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Ludovic Saba
- Department of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Teresa Gentile
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Dibyendu Dutta
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Seah H Lim
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
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McErlean G, Bajel A, Bhattacharyya A, Brown N, De Abreu Lourenco R, Greenwood M, Kerridge I, Kim N, Kliman D, Maneze D, O'Brien T, Szer J, Twist I. If we do not count it, it does not count: ethnicity in allogeneic haemopoietic stem cell transplant in Australia. Intern Med J 2023; 53:2155-2158. [PMID: 37814833 DOI: 10.1111/imj.16232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/20/2023] [Indexed: 10/11/2023]
Affiliation(s)
- Gemma McErlean
- School of Nursing, University of Wollongong, Wollongong, New South Wales, Australia
- St George Hospital, South Eastern Sydney Local Health District, New South Wales, Sydney, Australia
| | - Ashish Bajel
- Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Abir Bhattacharyya
- Department of Haematology, Westmead Hospital, New South Wales, Sydney, Australia
| | - Ngaire Brown
- Ngaoara Ltd, Wollongong, New South Wales, Australia
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Matthew Greenwood
- Department of Haematology, Royal North Shore Hospital, New South Wales, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Ian Kerridge
- Department of Haematology, Royal North Shore Hospital, New South Wales, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Nancy Kim
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - David Kliman
- Department of Haematology, Royal North Shore Hospital, New South Wales, Sydney, Australia
| | - Della Maneze
- School of Nursing, University of Wollongong, Wollongong, New South Wales, Australia
| | - Tracey O'Brien
- Cancer Institute NSW, NSW Health, Sydney, New South Wales, Australia
- University of New South Wales, School of Clinical Medicine, New South Wales, Sydney, Australia
| | - Jeff Szer
- Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Ida Twist
- Cancer Centre for Children, Children's Hospital Westmead, New South Wales, Sydney, Australia
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8
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Auletta JJ, Holter-Chakrabarty J, Jain T, Miller B, Ward E, Khera N, Gomez-Arteaga A, Hall A, Nemecek E, Robb D, Yusuf RA, Davies SM. Proceedings of the 2023 Second Annual ASTCT-NMDP ACCESS Initiative Workshop. Transplant Cell Ther 2023; 29:739-746. [PMID: 37805142 DOI: 10.1016/j.jtct.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 09/29/2023] [Indexed: 10/09/2023]
Abstract
Here the proceedings from the Second Annual American Society for Transplantation and Cellular Therapy (ASTCT) and National Marrow Donor Program (NMDP) ACCESS Initiative are reviewed to inform the hematopoietic cell transplantation (HCT) and cellular therapy (CT) ecosystem about progress and direction of the collaborative. Highlights from the meeting, including updates on the progress of projects from the Awareness, Poverty, and Racial Inequity Committees, are presented. The ACCESS Initiative continues to evolve and will remain dependent on the HCT/CT ecosystem's continued dedication to reduce barriers and improve outcome disparities for all patients in need of HCT/CT.
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Affiliation(s)
- Jeffery J Auletta
- National Marrow Donor Program, Minneapolis, Minnesota; Hematology/Oncology/Blood and Marrow Transplant and Infectious Diseases; Nationwide Children's Hospital, Columbus, Ohio.
| | | | - Tania Jain
- Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Becca Miller
- National Marrow Donor Program, Minneapolis, Minnesota
| | - Emily Ward
- National Marrow Donor Program, Minneapolis, Minnesota
| | | | | | | | | | - Delilah Robb
- National Marrow Donor Program, Minneapolis, Minnesota
| | | | - Stella M Davies
- Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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9
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Blue BJ, Brazauskas R, Chen K, Patel J, Zeidan AM, Steinberg A, Ballen K, Kwok J, Rotz SJ, Perez MAD, Kelkar AH, Ganguly S, Wingard JR, Lad D, Sharma A, Badawy SM, Lazarus HM, Hashem H, Szwajcer D, Knight JM, Bhatt NS, Page K, Beattie S, Arai Y, Liu H, Arnold SD, Freytes CO, Abid MB, Beitinjaneh A, Farhadfar N, Wirk B, Winestone LE, Agrawal V, Preussler JM, Seo S, Hashmi S, Lehmann L, Wood WA, Rangarajan HG, Saber W, Majhail NS. Racial and Socioeconomic Disparities in Long-Term Outcomes in ≥1 Year Allogeneic Hematopoietic Cell Transplantation Survivors: A CIBMTR Analysis. Transplant Cell Ther 2023; 29:709.e1-709.e11. [PMID: 37482244 PMCID: PMC11258715 DOI: 10.1016/j.jtct.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
Racial/ethnic minorities have demonstrated worse survival after allogeneic hematopoietic cell transplantation (HCT) compared to whites. Whether the racial disparity in HCT outcomes persists in long-term survivors and possibly may be even exacerbated in this population, which frequently transitions back from the transplant center to their local healthcare providers, is unknown. In the current study, we compared long-term outcomes among 1-year allogeneic HCT survivors by race/ethnicity and socioeconomic status (SES). The Center for International Blood and Marrow Transplant Research database was used to identify 5473 patients with acute myeloid leukemia, acute lymphocytic leukemia, chronic myeloid leukemia, or myelodysplastic syndromes who underwent their first allogeneic HCT between 2007 and 2017 and were alive and in remission for at least 1 year after transplantation. The study was restricted to patients who underwent HCT in the United States. SES was defined using patient neighborhood poverty level estimated from the recipient's ZIP code of residence; a ZIP code with ≥20% of persons below the federal poverty level was considered a high poverty area. The primary outcome was to evaluate the associations of race/ethnicity and neighborhood poverty level with overall survival (OS), relapse, and nonrelapse mortality (NRM). Cox regression models were used to determine associations of ethnicity/race and SES with OS, relapse, and NRM. Standardized mortality ratios were calculated to compare mortality rates of the study patients and their general population peers matched on race/ethnicity, age, and sex. The study cohort was predominately non-Hispanic white (n = 4385) and also included non-Hispanic black (n = 338), Hispanic (n = 516), and Asian (n = 234) patients. Overall, 729 patients (13%) resided in high-poverty areas. Significantly larger proportions of non-Hispanic black (37%) and Hispanic (26%) patients lived in high-poverty areas compared to non-Hispanic whites (10%) and Asians (10%) (P < .01). Multivariable analysis revealed no significant associations between OS, PFS, relapse, or NRM and race/ethnicity or poverty level when adjusted for patient-, disease- and transplantation-related covariates. Our retrospective cohort registry study shows that among adult allogeneic HCT recipients who survived at least 1 year in remission, there were no associations between race/ethnicity, neighborhood poverty level, and long-term outcomes.
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Affiliation(s)
| | - Ruta Brazauskas
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Karen Chen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jinalben Patel
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, Yale University, New Haven, CT
| | | | - Karen Ballen
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, VA
| | - Janette Kwok
- Division of Transplantation and Immunogenetics, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH
| | - Miguel Angel Diaz Perez
- Department of Hematology/Oncology, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
| | - Amar H Kelkar
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | - John R Wingard
- Division of Hematology & Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | - Deepesh Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, India
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN
| | - Sherif M Badawy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Hematology, Oncology, and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - David Szwajcer
- Cancer Care Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jennifer M Knight
- Section of BMT & Cellular Therapies; Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI; Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI
| | - Neel S Bhatt
- University of Washington School of Medicine, Department of Pediatrics, Division of Hematology/Oncology, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Kristin Page
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Sara Beattie
- Department of Psychosocial Oncology and Rehabilitation, Tom Baker Cancer Centre, Calgary, Canada; Department of Oncology, University of Calgary, Canada
| | - Yasuyuki Arai
- Kyoto University Hospital, Kyoto University, Kyoto, Japan
| | - Hongtao Liu
- Section of Hematology/Oncology, University of Chicago Medicine, Chicago, IL
| | - Staci D Arnold
- Aflac Cancer and Blood Disorder Center Children's Healthcare of Atlanta Emory University, Atlanta, GA
| | - César O Freytes
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Muhammad Bilal Abid
- Divisions of Hematology/Oncology & Infectious Diseases, BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, WI
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, PA
| | - Lena E Winestone
- Division of Allergy, Immunology, and Blood & Marrow Transplant, University of California San Francisco Benioff Children's Hospitals, San Francisco, CA
| | - Vaibhav Agrawal
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Jaime M Preussler
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, MN
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Shahrukh Hashmi
- Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE; Mayo Clinic Cancer Center, Mayo Clinic, Rochester, MN; College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, UAE
| | - Leslie Lehmann
- Dana-Farber Cancer Institute/Boston Children's Hospital, Boston, MA
| | - William A Wood
- Division of Hematology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Hemalatha G Rangarajan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Nationwide Children's hospital, Columbus, OH
| | - Wael Saber
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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10
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Malard F, Holler E, Sandmaier BM, Huang H, Mohty M. Acute graft-versus-host disease. Nat Rev Dis Primers 2023; 9:27. [PMID: 37291149 DOI: 10.1038/s41572-023-00438-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/10/2023]
Abstract
Acute graft-versus-host disease (GVHD) is a common immune complication that can occur after allogeneic haematopoietic cell transplantation (alloHCT). Acute GVHD is a major health problem in these patients, and is associated with high morbidity and mortality. Acute GVHD is caused by the recognition and the destruction of the recipient tissues and organs by the donor immune effector cells. This condition usually occurs within the first 3 months after alloHCT, but later onset is possible. Targeted organs include the skin, the lower and upper gastrointestinal tract and the liver. Diagnosis is mainly based on clinical examination, and complementary examinations are performed to exclude differential diagnoses. Preventive treatment for acute GVHD is administered to all patients who receive alloHCT, although it is not always effective. Steroids are used for first-line treatment, and the Janus kinase 2 (JAK2) inhibitor ruxolitinib is second-line treatment. No validated treatments are available for acute GVHD that is refractory to steroids and ruxolitinib, and therefore it remains an unmet medical need.
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Affiliation(s)
- Florent Malard
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France.
| | - Ernst Holler
- University Hospital of Regensburg, Department of Internal Medicine 3, Regensburg, Germany
| | - Brenda M Sandmaier
- Fred Hutchinson Cancer Center, Translational Science and Therapeutics Division, Seattle, WA, USA
- University of Washington School of Medicine, Division of Medical Oncology, Seattle, WA, USA
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Province, Hangzhou, China
- Engineering Laboratory for Stem Cell and Immunity Therapy, Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Mohamad Mohty
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France.
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11
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Prem S, Remberger M, Alotaibi A, Lam W, Law AD, Kim DDH, Michelis FV, Al-Shaibani Z, Lipton JH, Mattsson J, Viswabandya A, Kumar R, Ellison C. Relationship between certain HLA alleles and the risk of cytomegalovirus reactivation following allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2022; 24:e13879. [PMID: 35706108 DOI: 10.1111/tid.13879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/20/2022] [Accepted: 05/31/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Evidence is emerging to support an association between certain HLA alleles and the risk of cytomegalovirus (CMV) reactivation following allogeneic HSCT (allo-HSCT). The primary aim of this study was to identify HLA alleles associated with resistance or susceptibility to CMV reactivation. METHODS We studied 586 adults who underwent allo-HSCT for high-risk hematological malignancies. High resolution HLA typing data was available for recipient and donor. HLA Class I and II alleles observed at a frequency of > 5% in our population, were included in the analysis. A CMV viremia level of more than 200 IU/ml on weekly monitoring was considered to be indicative of CMV reactivation. RESULTS The median follow-up time in surviving patients was 21 months (range 4-74 months). The cumulative incidence of CMV reactivation at 6 months in the entire cohort was 55% (95% CI 50.8%-59.2%). Mismatched donor, increasing recipient age, occurrence of AGVHD and recipient CMV seropositivity were associated with increased risk of CMV reactivation. HLA B*07:02 (HR 0.59, 95% CI 0.40-0.83) was associated with decreased risk of CMV reactivation. Patients who developed CMV reactivation had a lower incidence of relapse, higher transplant related mortality (TRM) and lower overall survival (OS) compared to those without CMV reactivation. There was an adverse correlation of OS and TRM with increasing numbers of CMV reactivations. CONCLUSION We observed that HLA B*07:02 was associated with decreased risk of CMV reactivation. CMV reactivation was associated with lower relapse post-transplant, but this did not translate into a survival benefit due to higher transplant related mortality. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Shruti Prem
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Mats Remberger
- Department of Medical Sciences, Uppsala University and KFUE, Uppsala University Hospital, Uppsala, Sweden
| | - Ahmad Alotaibi
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Wilson Lam
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Arjun Datt Law
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Dennis Dong Hwan Kim
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Fotios V Michelis
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Zeyad Al-Shaibani
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Howard Lipton
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jonas Mattsson
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Auro Viswabandya
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Rajat Kumar
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Cynthia Ellison
- HLA Laboratory, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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12
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Morishima Y, Morishima S, Stevenson P, Kodera Y, Horowitz M, McKallor C, Malkki M, Spellman SR, Gooley T, Petersdorf EW. Race and Survival in Unrelated Hematopoietic Cell Transplantation. Transplant Cell Ther 2022; 28:357.e1-357.e6. [PMID: 35405366 DOI: 10.1016/j.jtct.2022.03.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/14/2022] [Accepted: 03/30/2022] [Indexed: 11/18/2022]
Abstract
Survival after hematopoietic cell transplantation depends on race/ethnicity and histocompatibility (HLA) between the patient and transplant donor. HLA sequence variation is a genetic construct of continental populations, but its role in accounting for racial disparities of transplant outcome is unknown. To determine disparities in transplant survivorship among patients of diverse race while accounting for patient and donor HLA variation. A total of 26,945 self-described Japanese, U.S. Asian, White, Hispanic, and Black patients received an unrelated donor transplant for the treatment of a life-threatening blood disorder. The risk of mortality with and without adjustment for known HLA risk factors (number and location of donor mismatches; patient HLA-B leader genotype and HLA-DRβ peptide-binding motif) was studied using multivariable models. Survival after HLA-matched transplantation for patients with optimal leader and peptide-binding features was estimated for each race, as was the improvement in survival over calendar-year time by considering year of transplantation as a continuous linear variable. The number, location, and nature of donor HLA mismatches and the frequency of patient HLA-B and HLA-DRB1 sequence motifs differed by race. Japanese patients had superior survival compared to other races without consideration of HLA. After HLA adjustment, three mortality risk strata were identified: Japanese and U.S. Asian (low-risk); White and Hispanic (intermediate-risk), and Black patients (high-risk). Survival for patients with optimal donor and HLA characteristics was superior for Japanese, intermediate for U.S. Asian, White, and Hispanic, and lowest for Black patients. Five-year increments of transplant year were associated with greater decreases in mortality hazards for Black and Hispanic patients than for Japanese, U.S. Asian and White patients. Transplant survivorship disparities are influenced by HLA as a genetic construct of race. A more complete understanding of the factors that influence transplant outcomes provides opportunities to narrow disparities for future patients.
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Affiliation(s)
- Yasuo Morishima
- Department of Promotion for Blood and Marrow Transplantation, Aichi Medical University, Nagakute Japan; Department of Hematology and Oncology, Nakagami Hospital, Okinawa, Japan.
| | - Satoko Morishima
- Division of Endocrinology, Diabetes and Metabolism, Hematology and Rheumatology, Second Department of Internal Medicine, Graduate School of Medicine, University of the Ryukyus, Nishihara, Japan
| | - Phil Stevenson
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yoshihisa Kodera
- Japan Marrow Donor Program, Tokyo, Japan; Center for Hematopoietic Stem Cell Transplantation, Aichi Medical University Hospital, Nagakute, Japan
| | - Mary Horowitz
- Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin; Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Caroline McKallor
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mari Malkki
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Ted Gooley
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Effie W Petersdorf
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington.
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13
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Cooper JP, Perkins JD, Warner PR, Shingina A, Biggins SW, Abkowitz JL, Reyes JD. Acute Graft-Versus-Host Disease After Orthotopic Liver Transplantation: Predicting This Rare Complication Using Machine Learning. Liver Transpl 2022; 28:407-421. [PMID: 34587357 PMCID: PMC9297869 DOI: 10.1002/lt.26318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 01/13/2023]
Abstract
Acute graft-versus-host disease (GVHD) is a rare complication after orthotopic liver transplantation (OLT) that carries high mortality. We hypothesized that machine-learning algorithms to predict rare events would identify patients at high risk for developing GVHD. To develop a predictive model, we retrospectively evaluated the clinical features of 1938 donor-recipient pairs at the time they underwent OLT at our center; 19 (1.0%) of these recipients developed GVHD. This population was divided into training (70%) and test (30%) sets. A total of 7 machine-learning classification algorithms were built based on the training data set to identify patients at high risk for GVHD. The C5.0, heterogeneous ensemble, and generalized gradient boosting machine (GGBM) algorithms predicted that 21% to 28% of the recipients in the test data set were at high risk for developing GVHD, with an area under the receiver operating characteristic curve (AUROC) of 0.83 to 0.86. The 7 algorithms were then evaluated in a validation data set of 75 more recent donor-recipient pairs who underwent OLT at our center; 2 of these recipients developed GVHD. The logistic regression, heterogeneous ensemble, and GGBM algorithms predicted that 9% to 11% of the validation recipients were at high risk for developing GVHD, with an AUROC of 0.93 to 0.96 that included the 2 recipients who developed GVHD. In conclusion, we present a practical model that can identify patients at high risk for GVHD who may warrant additional monitoring with peripheral blood chimerism testing.
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Affiliation(s)
- Jason P. Cooper
- Division of HematologyDepartment of MedicineUniversity of WashingtonSeattleWA
| | - James D. Perkins
- Division of Transplant SurgeryUniversity of WashingtonSeattleWA,Clinical and Bio‐Analytics Transplant Laboratory in the Department of Surgery at the University of Washington School of MedicineSeattleWA
| | | | - Alexandra Shingina
- Division of GastroenterologyDepartment of MedicineUniversity of WashingtonSeattleWA,Present address:
Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical CenterNashvilleTN
| | - Scott W. Biggins
- Clinical and Bio‐Analytics Transplant Laboratory in the Department of Surgery at the University of Washington School of MedicineSeattleWA,Division of GastroenterologyDepartment of MedicineUniversity of WashingtonSeattleWA
| | - Janis L. Abkowitz
- Division of HematologyDepartment of MedicineUniversity of WashingtonSeattleWA
| | - Jorge D. Reyes
- Division of Transplant SurgeryUniversity of WashingtonSeattleWA,Clinical and Bio‐Analytics Transplant Laboratory in the Department of Surgery at the University of Washington School of MedicineSeattleWA
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14
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Sigmund AM, Zhao Q, Jiang J, Elder P, Benson DM, Rosko A, Bumma N, Khan A, Devarakonda S, Vasu S, Jaglowski S, Mims A, Choe H, Larkin K, Brammer J, Wall S, Grieselhuber N, Saad A, Penza S, Efebera YA, Sharma N. Impact of Race and Geographic Area of Residence on Outcomes After Allogeneic Stem Cell Transplant. Front Oncol 2022; 12:801879. [PMID: 35280722 PMCID: PMC8913574 DOI: 10.3389/fonc.2022.801879] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/25/2022] [Indexed: 12/02/2022] Open
Abstract
Background Allogeneic hematopoietic stem cell transplant (allo-HCT) is a potential curative therapy for a variety of hematologic disorders. However, it requires highly specialized care that is only available at select centers across the country. Thus, minority populations are at risk for healthcare disparities in access to and outcomes of allo-HCT. Our study aimed to assess the impact of race and location of residence on outcomes of allo-HCT. Methods We performed a retrospective analysis of all patients who underwent allo-HCT at the Ohio State University from 1984 to 2018. Patients were divided by race (Caucasian, African American, and other) and grouped by zip code into rural, suburban, and urban groups. Primary endpoints included progression-free survival (PFS) and overall survival (OS). Results Of the 1,943 patients included in the study, 94.3% self-identified as Caucasian, 4.6% African American, and 1.1% other. In total, 63.4% lived in rural areas, 22.9% suburban, and 13.8% urban. There was no significant difference in OS or PFS by race (p = 0.15, 0.21) or place of residence (p = 0.39, 0.17). In addition, no difference in nonrelapse mortality, acute and chronic graft-versus-host disease (GVHD), and GVHD-free relapse-free survival (GRFS) was seen among the race or place of residence. Conclusion Our study suggests that when appropriate access to HCT is given, there is no difference in outcomes based on race, ethnicity or place of primary residence. Further research is needed to further evaluate barriers for these patients to undergo transplant and help mitigate these barriers.
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Affiliation(s)
- Audrey M. Sigmund
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Qiuhong Zhao
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Justin Jiang
- College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Patrick Elder
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Don M. Benson
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Ashley Rosko
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Naresh Bumma
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Abdullah Khan
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Srinivas Devarakonda
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Sumithira Vasu
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Samantha Jaglowski
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Alice Mims
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Hannah Choe
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Karilyn Larkin
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Jonathan Brammer
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Sarah Wall
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Nicole Grieselhuber
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Ayman Saad
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Sam Penza
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Yvonne A. Efebera
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Nidhi Sharma
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
- *Correspondence: Nidhi Sharma,
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15
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Mukherjee A, Gooley T, Mielcarek M, Sandmaier BM, Doney K, Oshima MU, Holmberg L, Baker KS, Salit RB, Krakow EF, Shannon-Dorcy K, Davis C, Lee SJ. Outcomes after hematopoietic cell transplantation among non-English- compared to English-speaking recipients. Bone Marrow Transplant 2022; 57:440-444. [DOI: 10.1038/s41409-021-01557-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/03/2021] [Accepted: 12/16/2021] [Indexed: 11/09/2022]
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16
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Landry I. Racial disparities in hematopoietic stem cell transplant: a systematic review of the literature. Stem Cell Investig 2021; 8:24. [PMID: 35071585 PMCID: PMC8743384 DOI: 10.21037/sci-2021-058] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 12/06/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplant (HSCT) is an expensive and complex treatment regimen that can be curative in many diseases of the bone marrow, including malignant and non-malignant conditions. The introduction of the Affordable Care Act increased access to potential candidates and removed or reduced many barriers previously identified in the literature, however, racial disparities continue to persist. As HSCT expands its utilization and indications, there is a continued need to understand the multifactorial barriers which lead to inequalities in transplant referral, utilization, and survival. The objective of this systematic review is to summarize these racial disparities, expand the current understanding of the literature, and determine whether the increases in insurance status from Medicaid expansion have played a role in HSCT utilization and survival rates by race. METHODS We explored studies based on retrospective reviews, literature reviews, and focus groups with the key-terms of 'race', 'hematopoietic stem cell transplant', and 'disparities'. The included studies were extracted from Cochrane and Medline databases. After screening for relevancy to research aims and objectives, 10 articles were utilized for background information and discussion, while 30 articles were categorized into main groups of outcomes, chiefly, (I) access/referral to transplant and (II) survival. RESULTS Eight of the eleven retrospective reviews found substantial variation in access to HSCT by ethnic minorities (Black, Hispanic, or Asian) when compared to their Caucasian counterparts. Thirteen of the fourteen publications found racial disparities in either overall survival, progression free survival, treatment related mortality, relapse, or combinations of these outcomes. The majority of the studies evaluated African American patients with six of eight studies showing significantly elevated mortality compared to Caucasian patients. DISCUSSION Substantial variation exists in access to HSCT, particularly in black patients. Having less generous insurance coverage was previously hypothesized to reduce the likelihood of HSCT utilization. Studies performed after full implementation of the Affordable Care Act continue to show poorer survival among ethnic minorities, particularly black patients, despite this increased coverage. Perceived racial bias and health-related stigma, as well as physician decisions and delay in referral process are likely contributing factors.
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Affiliation(s)
- Ian Landry
- Internal Medicine, Icahn School of Medicine at Mt Sinai, Queens Hospital Center, Jamaica, Queens, NY, USA
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17
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Horn B, Lamba N, Chellapandian D, Sunkersett G, Silva JG, Ziga E, Alperstein W, Joyce M, Castillo P, Fort J, Zhao J, Oshrine B. Race as a factor in donor selection and survival of children with hematologic malignancies undergoing hematopoietic stem cell transplant in Florida. Pediatr Blood Cancer 2021; 68:e29180. [PMID: 34121322 DOI: 10.1002/pbc.29180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/12/2021] [Accepted: 05/25/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previous studies have explored posthematopoietic cell transplant (HCT) outcomes by race in adults; however, pediatric data addressing this topic are scarce. PROCEDURE This retrospective registry study included 238 White (W) and 57 Black (B) children with hematologic malignancies (HM) receiving first allogeneic HCT between 2010 and 2019 at one of the five Florida pediatric HCT centers. RESULTS We found no differences between W and B children in transplant characteristics, other than donor type. There was a significant difference in use of human leukocyte antigen (HLA)-mismatched donors (HLA-MMD) (53% W, 71% B, p = .01). When comparing HLA-MMD use to fully HLA-matched donors, B had relative risk (RR) of 1.47 (95% CI 0.7-3) of receiving a mismatched unrelated donor (MMUD), RR of 2.34 (95% CI 1.2-4.4) of receiving a mismatched related donor (MMRD), and RR of 1.9 (95% CI 0.99-3.6) of receiving a mismatched cord blood donor (MMCBD) HCT, respectively. There was no significant difference in the incidence of aGVHD (48% W, 35% B), p = .1, or cGVHD (19% W, 28% B, p = .1), or primary cause of death. Overall 24-month survival was 61% (95% CI 55%-68%) for W, and 60% (95% CI 48-75) for B children, log-rank p = .7. While HLA matching improved survival in W children, the number of B children receiving HLA-matched HCT was too small to identify the impact of HLA matching on survival. CONCLUSIONS In this contemporary cohort of children with HM, we found that B children were more likely to receive HLA-MMD transplants, but this did not adversely affect survival or GVHD rates.
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Affiliation(s)
- Biljana Horn
- University of Florida, Gainesville, Florida, USA
| | - Nikhil Lamba
- University of Florida, Gainesville, Florida, USA
| | - Deepak Chellapandian
- Center for Cell and Gene Therapy for Nonmalignant Conditions, Blood and Marrow Transplant Program, Cancer & Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Gauri Sunkersett
- Center for Cell and Gene Therapy for Nonmalignant Conditions, Blood and Marrow Transplant Program, Cancer & Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | | | - Edward Ziga
- Pediatric Hematology and Oncology, University of Miami School of Medicine, Miami, Florida, USA
| | - Warren Alperstein
- Pediatric Hematology and Oncology, University of Miami School of Medicine, Miami, Florida, USA
| | - Michael Joyce
- Nemours Children's Clinic and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | | | - John Fort
- University of Florida, Gainesville, Florida, USA
| | - Jing Zhao
- University of Florida, Gainesville, Florida, USA
| | - Benjamin Oshrine
- Center for Cell and Gene Therapy for Nonmalignant Conditions, Blood and Marrow Transplant Program, Cancer & Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
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18
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Horiguchi M, Hata S, Tsurudome Y, Ushijima K. Characterizing the degeneration of nuclear membrane and mitochondria of adipose-derived mesenchymal stem cells from patients with type II diabetes. J Cell Mol Med 2021; 25:4298-4306. [PMID: 33759360 PMCID: PMC8093988 DOI: 10.1111/jcmm.16484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/22/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
Regenerative therapeutic approaches involving the transplantation of stem cells differentiated into insulin‐producing cells are being studied in patients with rapidly progressing severe diabetes. Adipose‐derived mesenchymal stem cells have been reported to have varied cellular characteristics depending on the biological environment of the location from which they were harvested. However, the characteristics of mesenchymal stem cells in type II diabetes have not been clarified. In this study, we observed the organelles of mesenchymal stem cells from patients with type II diabetes under a transmission electron microscope to determine the structure of stem cells in type II diabetes. Transmission electron microscopic observation of mesenchymal stem cells from healthy volunteers (N‐ADSC) and those from patients with type II diabetes (T2DM‐ADSC) revealed enlarged nuclei and degenerated mitochondrial cristae in T2DM‐ADSCs. Moreover, T2DM‐ADSCs were shown to exhibit a lower expression of Emerin, a constituent protein of the nuclear membrane, and a decreased level of mitochondrial enzyme activity. In this study, we successfully demonstrated the altered structure of nuclear membrane and the decreased mitochondrial enzyme activity in adipose‐derived mesenchymal cells from patients with type II diabetes. These findings have contributed to the understanding of type II diabetes‐associated changes in mesenchymal stem cells used for regenerative therapy.
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Affiliation(s)
- Michiko Horiguchi
- Division of Pharmaceutics, Faculty of Pharmaceutical Sciences, Sanyo-Onoda City University, Sanyoonoda, Japan
| | - Shinichi Hata
- Department of Applied Chemistry, Faculty of Engineering, Sanyo-Onoda City University, Sanyoonoda, Japan
| | - Yuya Tsurudome
- Division of Pharmaceutics, Faculty of Pharmaceutical Sciences, Sanyo-Onoda City University, Sanyoonoda, Japan
| | - Kentaro Ushijima
- Division of Pharmaceutics, Faculty of Pharmaceutical Sciences, Sanyo-Onoda City University, Sanyoonoda, Japan
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19
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Jeurkar C, Leiby B, Banks J, Leader A, Rudolph S, Mateja G, Rashid SA, Carabasi M, Filicko-O'Hara J, O'Hara W, Wagner JL, Gergis U, Flomenberg N, Grosso D. An Examination of Cytomegalovirus, Socioeconomic Status, Race, and Ethnicity on Outcomes after Haploidentical Hematopoietic Transplantation. Transplant Cell Ther 2020; 27:327.e1-327.e11. [PMID: 33836876 DOI: 10.1016/j.jtct.2020.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/14/2020] [Accepted: 11/22/2020] [Indexed: 11/19/2022]
Abstract
Previous analyses of the effects of race and socioeconomic status (SES) on outcomes after hematopoietic stem cell transplantation (HSCT) have suggested that minority populations and those in disadvantaged groups have inferior outcomes. However, the results of these studies have been inconsistent, potentially due to a multitude of factors, both medical and nonmedical, that have confounded results. In haploidentical (HI) HSCT, an expanding approach with the potential to enfranchise more minority patients, data on the effect of race and SES on outcomes are very limited. To identify and potentially correct factors that negatively impact outcomes after HI HSCT in disadvantaged groups at our institution, we performed a retrospective, multivariable analysis of the impact of race and SES as single and combined variables on HI HSCT outcomes of relapse, transplantation-related mortality, acute and chronic graft-versus-host disease (GVHD), and overall survival (OS). In addition to controlling for race and SES, all patients had HI donors and were treated with the same 2-step approach, with consistent T cell dosing and GVHD prophylaxis to further reduce the impact of confounders in this complex area. The study cohort of 239 patients was 71% Caucasian, 19.7% African American, 4.6% Hispanic, and 4.2% Asian. The majority of minority patients were in areas of higher deprivation (P = .001) and had the highest incidence of cytomegalovirus (CMV) seropositivity (P = .001) and the lowest likelihood of possessing a CMV immunodominant (IMD) allele (P = .001), which was previously associated with an OS benefit. Positive CMV serostatus was highly linked to post-transplantation CMV reactivation (P = .001) which was associated with higher relapse rates (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.06 to 2.30; P = .026), higher TRM (HR, 2.10; 95% CI, 1.09 to 4.05; P = .027), and lower OS (HR, 1.77; 95% CI, 1.18 to 2.65; P = .006). The lack of a CMV IMD allele largely replicated the results of CMV reactivation on HSCT results. Although race and SES did not directly correlate with either OS or relapse incidence, non-Caucasians in a more disadvantaged group had a higher incidence of chronic GVHD (HR, 2.55; 95% CI, 1.08 to 6.01; P = .033) compared with Caucasians and minorities in less disadvantaged groups. Regardless of SES, minorities had a lower incidence of acute GVHD than Caucasians in a more advantaged SES group (HR, 0.52; 95% CI, 0.30 to 0.90; P = .020). The primary finding of this study is that CMV reactivation was the major driver of mortality after HI HSCT. CMV reactivation may have be associated with poor HSCT outcomes in HI HSCT recipients in disadvantaged areas, most of whom were minorities. The data suggest that the prevention of post-transplantation CMV reactivation possibly could have a major impact on HI HSCT outcomes, especially in minority recipients. The finding of different GVHD manifestations between races are intriguing and merits further study.
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Affiliation(s)
- Chetan Jeurkar
- Department of Medical Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Benjamin Leiby
- Pharmacology and Experimental Therapeutics, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joshua Banks
- Pharmacology and Experimental Therapeutics, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Amy Leader
- Division of Population Science, Department of Medical Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Shannon Rudolph
- Clinical Research Organization, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Gina Mateja
- Clinical Research Organization, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Shaik Abdul Rashid
- Department of Medical Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew Carabasi
- Department of Medical Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joanne Filicko-O'Hara
- Department of Medical Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - William O'Hara
- Department of Medical Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - John L Wagner
- Department of Medical Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Usama Gergis
- Department of Medical Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Neal Flomenberg
- Department of Medical Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Dolores Grosso
- Department of Medical Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania.
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20
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Harney SM, Kahn JM, Jin Z, Wong P, McKetta S, Satwani P. Race and socioeconomic status in pediatric allogeneic hematopoietic cell transplantation for nonmalignant conditions. Pediatr Blood Cancer 2020; 67:e28367. [PMID: 32497418 DOI: 10.1002/pbc.28367] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Survival disparities by race/ethnicity and socioeconomic status (SES) are observed in a wide range of pediatric treatment settings including oncology and solid organ transplantation. To date, few studies have examined the effects of race and SES on outcomes in pediatric allogeneic hematopoietic cell transplantation (HCT). We explored whether survival differed by race/ethnicity or SES in children receiving HCT for nonmalignant conditions at a single institution serving a diverse patient population. PROCEDURES The Kaplan-Meier method was used to estimate overall survival (OS) with the log-rank test for between-group comparisons. Cox proportional hazards models were used to identify risk factors for OS, adjusting for treatment- and disease-related factors. RESULTS Of 133 subjects, 0 to 21 years, 19% were non-Hispanic (NH) white, 34% were NH black, 40% were Hispanic, and 7% were Asian. Sixty-seven percent of the subjects had public insurance; 49% lived in neighborhoods with poverty rate ≥20%. Primary diagnoses included hemoglobinopathies (56%), bone marrow failure (22%), and other conditions (22%). Median follow-up was 5.8 years (range 0.1-14.5). Analysis revealed no difference in OS by race, insurance type, or neighborhood SES. CONCLUSIONS Findings from this single-institution study suggest that in pediatric patients undergoing HCT for nonmalignant conditions, treatment at a tertiary care center with a multidisciplinary approach may mitigate drivers of disparities observed in other settings. Additional studies are now needed to further elucidate the complex interrelationships among race, SES, and clinical outcomes for children undergoing HCT.
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Affiliation(s)
- Sarah M Harney
- Department of Pediatrics, Hasbro Children's Hospital, Brown University, Providence, Rhode Island
| | - Justine M Kahn
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Priscilla Wong
- Compliance Department, New York City Housing Authority, New York, New York
| | - Sarah McKetta
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
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21
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Isaac EI, Meisman AR, Drucker K, Violante S, Behrhorst KL, Floyd A, Rohan JM. The Relationship between Health Disparities, Psychosocial Functioning and Health Outcomes in Pediatric Hematology-Oncology and Stem Cell Transplant Populations: Recommendations for Clinical Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2218. [PMID: 32224963 PMCID: PMC7178256 DOI: 10.3390/ijerph17072218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/20/2020] [Accepted: 03/22/2020] [Indexed: 01/09/2023]
Abstract
Not only do racial and ethnic minority children and adolescents with chronic illness experience disparities in health status and health outcomes, they also experience significant healthcare disparities, including differences in healthcare coverage, access to care, and quality of care. It is well known that the interaction between psychosocial functioning, health behaviors and ethnic and racial disparities, ultimately leads to worse health and psychosocial outcomes in pediatric and AYA chronic illness patient populations, including increased rates of morbidity and mortality. Investigating the impact of racial and ethnic factors on health outcomes, and strategies for reducing these disparities, is of the utmost importance, specifically in life-threatening conditions like cancer and sickle cell disease. This commentary underscores the relative importance of identifying factors that could reduce disparities between minority and non-minority populations. This present paper will focus on the dynamic relationships between health disparities, psychosocial factors and health outcomes within pediatric cancer, sickle cell disease and bone marrow transplant populations, and will offer recommendations for healthcare professionals working with these vulnerable patient populations. The primary goal of this commentary is to provide recommendations for enhancing cultural competency and humility for those working with highly vulnerable patient populations.
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Affiliation(s)
- Evrosina I. Isaac
- Virginia Commonwealth University School of Medicine, 1201 E. Marshall St #4-100, Richmond, VA 23298, USA; (K.D.); (J.M.R.)
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, VA 23219, USA; (S.V.); (K.L.B.); (A.F.)
| | - Andrea R. Meisman
- Division of Adolescent and Transition Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
| | - Kirstin Drucker
- Virginia Commonwealth University School of Medicine, 1201 E. Marshall St #4-100, Richmond, VA 23298, USA; (K.D.); (J.M.R.)
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, VA 23219, USA; (S.V.); (K.L.B.); (A.F.)
| | - Stephanie Violante
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, VA 23219, USA; (S.V.); (K.L.B.); (A.F.)
- Department of Psychology, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Kathryn L. Behrhorst
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, VA 23219, USA; (S.V.); (K.L.B.); (A.F.)
- Department of Psychology, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Alfonso Floyd
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, VA 23219, USA; (S.V.); (K.L.B.); (A.F.)
- Department of Psychology, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Jennifer M. Rohan
- Virginia Commonwealth University School of Medicine, 1201 E. Marshall St #4-100, Richmond, VA 23298, USA; (K.D.); (J.M.R.)
- Department of Psychology, Virginia Commonwealth University, Richmond, VA 23284, USA
- Massey Cancer Center Virginia Commonwealth University, Richmond, VA 23298, USA
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22
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Grosso D, Leiby B, Carabasi M, Filicko-O'Hara J, Gaballa S, O'Hara W, Wagner JL, Flomenberg N. The Presence of a CMV Immunodominant Allele in the Recipient Is Associated With Increased Survival in CMV Positive Patients Undergoing Haploidentical Hematopoietic Stem Cell Transplantation. Front Oncol 2019; 9:888. [PMID: 31608225 PMCID: PMC6758597 DOI: 10.3389/fonc.2019.00888] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/27/2019] [Indexed: 12/26/2022] Open
Abstract
Specific major histocompatibility (MHC) class I alleles dominate anti-CMV responses in a hierarchal manner. These CMV immunodominant (IMD) alleles are associated with a higher magnitude and frequency of cytotoxic lymphocyte responses as compared to other human leukocyte antigen (HLA) alleles. CMV reactivation has been associated with an increased incidence of graft-vs.-host disease and non-relapse mortality, as well as protection from relapse in HLA-matched HSCT settings. Less is known about the impact of CMV reactivation on these major outcomes after haploidentical (HI) HSCT, an increasingly applied therapeutic option. In HI HSCT, the efficiency of the immune response is decreased due to the immune suppression required to cross the MHC barrier as well as MHC mismatch between presenting and responding cells. We hypothesized that the presence of a CMV IMD allele would increase the efficiency of CMV responses after HI HSCT potentially impacting CMV-related outcomes. In this retrospective, multivariable review of 216 HI HSCT patients, we found that CMV+ recipients possessing at least 1 of 5 identified CMV IMD alleles had a lower hazard of death (HR = 0.40, p = 0.003) compared to CMV+ recipients not possessing a CMV IMD allele, and an overall survival rate similar to their CMV- counterparts. The analysis delineated subgroups within the CMV+ population at greater risk for death due to CMV reactivation.
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Affiliation(s)
- Dolores Grosso
- Blood and Marrow Transplant Program, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA, United States
| | - Benjamin Leiby
- Pharmacology and Experimental Therapeutics, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA, United States
| | - Matthew Carabasi
- Blood and Marrow Transplant Program, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA, United States
| | - Joanne Filicko-O'Hara
- Blood and Marrow Transplant Program, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA, United States
| | - Sameh Gaballa
- Blood and Marrow Transplant Program, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA, United States
| | - William O'Hara
- Blood and Marrow Transplant Program, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA, United States
| | - John L. Wagner
- Blood and Marrow Transplant Program, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA, United States
| | - Neal Flomenberg
- Blood and Marrow Transplant Program, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA, United States
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23
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Burnham JP, Rojek RP, Kollef MH. Catheter removal and outcomes of multidrug-resistant central-line-associated bloodstream infection. Medicine (Baltimore) 2018; 97:e12782. [PMID: 30334966 PMCID: PMC6211864 DOI: 10.1097/md.0000000000012782] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Central-line-associated bloodstream infections (CLABSIs) are responsible for ∼1/3 of all deaths from healthcare-associated infections in the United States. Of these, multidrug-resistant organisms (MDROs) are responsible for 20% to 67%. However, whether catheter removal affects clinical outcomes for MDRO CLABSIs has not been studied. Our objective was to determine the relationship between failure to remove a central venous catheter (CVC) and 30-day all-cause mortality in patients with MDRO CLABSIs. We used a retrospective cohort from Barnes-Jewish Hospital (1/1/2009-10/1/2015) to study patients with a multidrug-resistant Staphylococcus aureus, Enterococcus species, Enterobacteriaceae, Acinetobacter species, or Pseudomonas aeruginosa CLABSI. Risk factors for 30-day mortality, including catheter removal, were assessed for association with 30-day mortality using Cox proportional hazards models. The CLABSIs were assessed prospectively at the time of occurrence by infection prevention specialists. A total of 430 patients met inclusion criteria, 173 (40.2%) with Enterococcus, 116 (27.0%) Enterobacteriaceae, 81 (18.8%) S aureus, 44 (10.2%) polymicrobial, 11 (2.6%) P aeruginosa, and 5 (1.2%) Acinetobacter CLABSIs. Removal of a CVC occurred in 50.2% of patients, of which 4.2% died by 30 days (n = 9). For patients whose CVC remained in place, 45.3% died (n = 97). Failure to remove a CVC was strongly associated with 30-day all-cause mortality with a hazard ratio of 13.5 (6.8-26.7), P < .001. Other risk factors for 30-day mortality included patient comorbidities (cardiovascular disease, congestive heart failure, cirrhosis), and being in an intensive care unit at the time of MDRO isolation. Failure to remove a CVC was strongly associated with 30-day all-cause mortality for patients with MDRO CLABSIs in this single center retrospective cohort. This suggests that patients presenting with MDRO CLABSIs should all undergo CVC removal.
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Affiliation(s)
- Jason P. Burnham
- Division of Infectious Diseases, Washington University School of Medicine
| | | | - Marin H. Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO
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24
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Taylor DA, Willerson JT. Racial Disparities in CD34+ Cells and Their Influence on Cardiovascular Repair. Circ Res 2018; 123:401-403. [PMID: 30355257 DOI: 10.1161/circresaha.118.313546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Doris A Taylor
- From the Regenerative Medicine Research, Texas Heart Institute, Houston (D.A.T., J.T.W.).,Texas Heart Institute, Houston (D.A.T., J.T.W.)
| | - James T Willerson
- From the Regenerative Medicine Research, Texas Heart Institute, Houston (D.A.T., J.T.W.).,Texas Heart Institute, Houston (D.A.T., J.T.W.)
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25
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da Silva-Malta MCF, Rodrigues PS, Zuccherato LW, de Souza FCB, Domingues EMFL, Souza VR, Tarazona-Santos E, Martins ML. Human leukocyte antigen distribution and genomic ancestry in Brazilian patients with sickle cell disease. HLA 2017; 90:211-218. [DOI: 10.1111/tan.13102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 06/13/2017] [Accepted: 07/18/2017] [Indexed: 12/11/2022]
Affiliation(s)
- M. C. F. da Silva-Malta
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
| | - P. S. Rodrigues
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
| | - L. W. Zuccherato
- Departamento de Biologia Geral, Instituto de Ciências Biológicas; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
| | - F. C. B. de Souza
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
| | - E. M. F. L. Domingues
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
| | - V. R. Souza
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
| | - E. Tarazona-Santos
- Departamento de Biologia Geral, Instituto de Ciências Biológicas; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
| | - M. L. Martins
- Fundação Centro de Hematologia e Hemoterapia de Minas Gerais - Hemominas; Belo Horizonte Brazil
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Madbouly A, Wang T, Haagenson M, Paunic V, Vierra-Green C, Fleischhauer K, Hsu KC, Verneris MR, Majhail NS, Lee SJ, Spellman SR, Maiers M. Investigating the Association of Genetic Admixture and Donor/Recipient Genetic Disparity with Transplant Outcomes. Biol Blood Marrow Transplant 2017; 23:1029-1037. [PMID: 28263917 DOI: 10.1016/j.bbmt.2017.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/27/2017] [Indexed: 12/16/2022]
Abstract
Disparities in survival after allogeneic hematopoietic cell transplantation have been reported for some race and ethnic groups, despite comparable HLA matching. Individuals' ethnic and race groups, as reported through self-identification, can change over time because of multiple sociological factors. We studied the effect of 2 measures of genetic similarity in 1378 recipients who underwent myeloablative first allogeneic hematopoietic cell transplantation between 1995 and 2011 and their unrelated 10 of 10 HLA-A, -B, -C, -DRB1, and-DQB1- matched donors. The studied factors were as follows (1) donor and recipient genetic ancestral admixture and (2) pairwise donor/recipient genetic distance. Increased African genetic admixture for either transplant recipients or donors was associated with increased risk of overall mortality (hazard ratio [HR], 2.26; P = .005 and HR, 3.09; P = .0002, respectively) and transplant-related mortality (HR, 3.3; P = .0003 and HR, 3.86; P = .0001, respectively) and decreased disease-free survival (HR, 1.9; P = .02 and HR, 2.46; P = .002 respectively). The observed effect, albeit statistically significant, was relevant to a small subset of the studied population and was notably correlated with self-reported African-American race. We were not able to control for other nongenetic factors, such as access to health care or other socioeconomic factors; however, the results suggest the influence of a genetic driver. Our findings confirm what has been previously reported for African-American recipients and show similar results for donors. No significant association was found with donor/recipient genetic distance.
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Affiliation(s)
- Abeer Madbouly
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota.
| | - Tao Wang
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Haagenson
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Vanja Paunic
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Cynthia Vierra-Green
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | | | | | | | | | - Stephanie J Lee
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin; Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Martin Maiers
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
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27
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Sasazuki T, Inoko H, Morishima S, Morishima Y. Gene Map of the HLA Region, Graves’ Disease and Hashimoto Thyroiditis, and Hematopoietic Stem Cell Transplantation. Adv Immunol 2016; 129:175-249. [DOI: 10.1016/bs.ai.2015.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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28
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Crockett DG, Loberiza FR. Persistent Disparities in Adult Hematopoietic Cell Transplantation. Curr Hematol Malig Rep 2015; 10:192-8. [PMID: 26104908 DOI: 10.1007/s11899-015-0268-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of large databases has provided advancements in the understanding of racial, ethnic, and socioeconomic disparities in the field of adult hematopoietic cell transplants (HCT). Disparities exist on individual, institutional, and systemic levels for both allogeneic and autologous HCT. We reviewed the most recent publications that utilized large databases to elucidate disparities in HCT and placed them into historical context of the other major studies in the field. Two emerging themes were identified. These themes are persistent inequalities in both allogeneic HCT and autologous HCT for myeloma and the importance of improving homogeneity of care in HCT. Minimization of inequalities can be achieved only with an understanding of the persistent barriers that exist in the field.
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Affiliation(s)
- David G Crockett
- Section of Oncology/Hematology, Department of Internal Medicine, University of Nebraska Medical Center, 987680 Nebraska Medical Center, Omaha, NE, 68198-7680, USA,
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29
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Clay A, Peoples B, Zhang Y, Moysich K, Ross L, McCarthy P, Hahn T. Population-Based Analysis of Hematologic Malignancy Referrals to a Comprehensive Cancer Center, Referrals for Blood and Marrow Transplantation, and Participation in Clinical Trial, Survey, and Biospecimen Research by Race. Biol Blood Marrow Transplant 2015; 21:1488-94. [PMID: 25899454 DOI: 10.1016/j.bbmt.2015.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 04/13/2015] [Indexed: 12/15/2022]
Abstract
Racial and ethnic disparities have been reported in clinical trial/research participation, utilization of autologous and allogeneic blood and marrow transplantation (BMT), and availability of allogeneic donors. We performed a population-based cohort study to investigate adult hematologic malignancy referrals to a US tertiary cancer center, utilization of BMT, and participation in clinical trial, survey, and biospecimen research by race. US Census Data and the New York State Public Access Cancer Epidemiology Database identified the racial distribution of the general population and new hematologic malignancy cases in the primary catchment area. From 2005 to 2011, 1106 patients aged 18 to 75 years were referred for BMT consultation; although the rate of BMT among hematologic malignancy referrals did not differ by race, the reasons for not receiving a BMT did. Participation in biospecimen research did not vary by race; however, African Americans and other minorities were significantly less likely to participate in survey research than European Americans. Although rates of hematologic malignancy referrals and use of BMT for minorities appear to be low (<10%), they closely reflect the race distribution of all hematologic malignancy cases and the western New York population. African Americans are equally likely as other races to participate in biospecimen banking, but further study is needed to understand reasons for lower participation in survey research.
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Affiliation(s)
- Alyssa Clay
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Brittany Peoples
- Department of Cancer Prevention and Control, Roswell Park Cancer Institute, Buffalo, New York
| | - Yali Zhang
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Kirsten Moysich
- Department of Cancer Prevention and Control, Roswell Park Cancer Institute, Buffalo, New York
| | - Levi Ross
- Department of Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia
| | - Philip McCarthy
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Theresa Hahn
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York.
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30
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Racial differences in allogeneic hematopoietic cell transplantation outcomes among African Americans and whites. Bone Marrow Transplant 2015; 50:834-9. [DOI: 10.1038/bmt.2015.44] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 01/21/2015] [Accepted: 01/23/2015] [Indexed: 11/08/2022]
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31
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Johnston RE, Heitzeg MM. Sex, age, race and intervention type in clinical studies of HIV cure: a systematic review. AIDS Res Hum Retroviruses 2015; 31:85-97. [PMID: 25313793 DOI: 10.1089/aid.2014.0205] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This systematic review was undertaken to determine the extent to which adult subjects representing sex (female), race (nonwhite), and age (>50 years) categories are included in clinical studies of HIV curative interventions and thus, by extension, the potential for data to be analyzed that may shed light on the influence of such demographic variables on safety and/or efficacy. English-language publications retrieved from PubMed and from references of retrieved papers describing clinical studies of curative interventions were read and demographic, recruitment year, and intervention-type details were noted. Variables of interest included participation by sex, age, and race; changes in participation rates by recruitment year; and differences in participation by intervention type. Of 151 publications, 23% reported full demographic data of study enrollees, and only 6% reported conducting efficacy analyses by demographic variables. Included studies recruited participants from 1991 to 2011. No study conducted safety analyses by demographic variables. The representation of women, older people, and nonwhites did not reflect national or international burdens of HIV infection. Participation of demographic subgroups differed by intervention type and study location. Rates of participation of demographic groups of interest did not vary with time. Limited data suggest efficacy, particularly of early therapy initiation followed by treatment interruption, may vary by demographic variables, in this case sex. More data are needed to determine associations between demographic characteristics and safety/efficacy of curative interventions. Studies should be powered to conduct such analyses and cure-relevant measures should be standardized.
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Affiliation(s)
| | - Mary M. Heitzeg
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
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32
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Sorror ML, Estey E. Allogeneic hematopoietic cell transplantation for acute myeloid leukemia in older adults. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:21-33. [PMID: 25696831 DOI: 10.1182/asheducation-2014.1.21] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Acute myeloid leukemia (AML) is primarily a disease of the elderly and the numbers of these patients are increasing. Patients ≥60 years of age continue to have poor prognosis. Preliminary results suggest benefit from reduced-intensity allogeneic hematopoietic cell transplantation (HCT) in selected patients 60-80 years of age. However, although patients in this age range comprise >50% of those with AML, they currently constitute only 17% of those offered HCT. In the absence of prospective randomized studies comparing HCT and chemotherapy, the decision to recommend HCT rests on retrospective analyses of the risks of relapse and nonrelapse mortality after each approach. There is strong evidence that pre-HCT comorbidities can predict HCT-related morbidity and mortality. Age alone does not appear predictive and, particularly if the risk of relapse with chemotherapy is high, should not be the sole basis for deciding against HCT. Use of geriatric assessment tools, inflammatory biomarkers, and genetic polymorphism data may further aid in predicting nonrelapse mortality after HCT. Disease status and pretreatment cytogenetics with FLT3-TID, NPM-1, and CEBP-α status are the main factors predicting relapse and these are likely to be supplemented by incorporation of other molecular markers and the level of minimal residual disease after chemotherapy. HLA-matched related and unrelated donor grafts seem preferable to those from other donor sources. Donor age is of no clear significance. Models combining comorbidities with AML risk factors are useful in risk assessment before HCT. In this chapter, we integrated information on AML-specific, HCT-specific, and patient-specific risk factors into a risk-adapted approach to guide decisions about HCT versus no HCT.
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Affiliation(s)
- Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Research Center, and Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Elihu Estey
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
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33
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Khera N, Chang YH, Slack J, Fauble V, Leis JF, Noel P, Sproat L, Palmer J, Adams R, Fitch T, Northfelt D, Guy M, Tilburt J, Mikhael J. Impact of race and ethnicity on outcomes and health care utilization after allogeneic hematopoietic cell transplantation. Leuk Lymphoma 2014; 56:987-92. [PMID: 25012944 DOI: 10.3109/10428194.2014.941834] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Disparities in outcomes after hematopoietic cell transplant (HCT) are reported mostly by registry studies. We examined the association of self-reported race and ethnicity with outcomes and health care utilization after allogeneic HCT in a single center study. Clinical and socioeconomic data of 296 adult patients who underwent allogeneic HCT from November 2003 to October 2012 were analyzed. Survival was compared between non-Hispanic Whites (NHW) and minority patients using Cox proportional hazards regression. Some 73% of patients were NHW and 27% were racial/ethnic minority patients. More minority patients were younger and had lower socioeconomic status. Both unadjusted and adjusted overall and progression-free survival were comparable between the two groups. High risk disease, poor performance score and Medicare/Tricare were significant predictors of mortality. Health care utilization was comparable between the two groups. Homogeneity of medical care for allogeneic HCT may help overcome racial/ethnic disparities, but not those due to patients' primary insurance.
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34
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Eckrich MJ, Ahn KW, Champlin RE, Coccia P, Godder K, Horan J, Margolis D, Deeg H, Eapen M. Effect of race on outcomes after allogeneic hematopoietic cell transplantation for severe aplastic anemia. Am J Hematol 2014; 89:125-9. [PMID: 24122901 DOI: 10.1002/ajh.23594] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 09/16/2013] [Indexed: 11/06/2022]
Abstract
We compared outcomes after hematopoietic cell transplantation in patients of African American (n = 84) and Caucasian (n = 215) descent with severe aplastic anemia. African Americans and Caucasians were matched for age, donor-recipient human leukocyte antigen match, graft type, and transplantation year. The median follow-up of surviving patients was 5 years. In multivariate analysis, overall mortality risks were higher for African Americans compared to Caucasians (relative risk 1.73, P = 0.01). The 5-year probabilities of overall survival adjusted for interval from diagnosis to transplantation, and performance score was 58% for African Americans and 73% for Caucasians. The day-100 cumulative incidence of grade III-IV, but not grade II-IV acute graft-versus-host disease (GVHD), was higher in African Americans compared to Caucasians (29% vs. 13%, P = 0.006). Although the 5-year cumulative incidence of chronic GVHD was not significantly different between the racial groups, African Americans were more likely to have extensive chronic GVHD compared to Caucasians (72% vs. 49%, P = 0.06). Survival differences between Caucasians and African Americans can be attributed to multiple factors. Our data suggest that some of the observed survival differences between Caucasians and African Americans may be explained by higher rates of acute GVHD and severity of chronic GVHD.
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Affiliation(s)
- Michael J. Eckrich
- Department of Medicine; Center for International Blood and Marrow Transplant Research; Medical College of Wisconsin Milwaukee Wisconsin
| | - Kwang-Woo Ahn
- Department of Medicine; Center for International Blood and Marrow Transplant Research; Medical College of Wisconsin Milwaukee Wisconsin
- Division of Biostatistics; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Richard E. Champlin
- Department of Stem Cell Transplantation and Cellular Therapy; MD Anderson Cancer Center; Houston Texas
| | - Peter Coccia
- Division of Hematology/Oncology; University of Nebraska Medical Center; Omaha Nebraska
| | - Kamar Godder
- Division of Hematology and Oncology; Virginia Commonwealth University; Richmond Virginia
| | | | - David Margolis
- Division of Hematology/Oncology; Medical College of Wisconsin; Milwaukee Wisconsin
| | - H.Joachim Deeg
- Clinical Research Division; Fred Hutchinson Cancer Research Center; Seattle Washington
| | - Mary Eapen
- Department of Medicine; Center for International Blood and Marrow Transplant Research; Medical College of Wisconsin Milwaukee Wisconsin
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35
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Sorror ML, Appelbaum FR. Risk assessment before allogeneic hematopoietic cell transplantation for older adults with acute myeloid leukemia. Expert Rev Hematol 2013; 6:547-62. [PMID: 24083472 DOI: 10.1586/17474086.2013.827418] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute myeloid leukemia (AML) most commonly affects patients older than 60 years. Outcomes of treatment of older AML patients have been poor. The advent of reduced-intensity conditioning (RIC) regimens made allogeneic hematopoietic cell transplantation (HCT) an available treatment option with curative intent for older AML patients. Because older patients are often excluded from clinical trials, little is known about the stratification of their risks before allogeneic HCT. While recent studies of RIC and allogeneic HCT have shown little impact of age on outcomes, other variables such as the recipient health status and the AML disease status and chromosomal aberrations have proven to be of prognostic significance. Here, the authors review recent studies of allogeneic HCT for older patients with AML with detailed evaluation of risk factors for relapse as well as non-relapse mortality. The authors have integrated the currently available information on transplant risks into a five-category risk-benefit system that could aid in the decision-making in this patient population.
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Affiliation(s)
- Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle WA 98109-1024, USA
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36
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Morishima Y, Kawase T, Malkki M, Morishima S, Spellman S, Kashiwase K, Kato S, Cesbron A, Tiercy JM, Senitzer D, Velardi A, Petersdorf EW. Significance of ethnicity in the risk of acute graft-versus-host disease and leukemia relapse after unrelated donor hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2013; 19:1197-203. [PMID: 23747601 PMCID: PMC3972059 DOI: 10.1016/j.bbmt.2013.05.020] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 05/29/2013] [Indexed: 12/16/2022]
Abstract
The significance of patient and donor ethnicity on risk of acute graft-versus-host disease (GVHD) and disease relapse after unrelated donor hematopoietic cell transplantation (HCT) is not known. A total of 4335 patient-donor pairs from the International Histocompatibility Working Group in HCT met the following 3 criteria: (1) HLA-A, -B, -C, -DRB1, and -DQB1 allele matched donor, (2) diagnosis of leukemia, and (3) non-T cell depleted GVHD prophylaxis. Posttransplantation risks of acute GVHD and leukemia relapse were defined in Asian/Pacific Islander, white, African American, Hispanic, and Native American patients that underwent transplantation from donors with the same self-described background. Asian patients had a significantly lower incidence of acute GVHD (Japanese patients: 40.0% grades II to IV and 15.3% grades III to IV; non-Japanese Asian patients: 42.1% grades II to IV and 15.7% grades III to IV) compared with white patients (56.5% grades II to IV and 22.6% grades III to IV) (P < .001). The hazard ratio of acute GVHD for white patients was significantly higher than for Japanese patients. Unexpectedly, the hazard ratio of leukemia relapse in white patients with early disease status was also significantly higher than that in Japanese patients. These results provide a platform for future investigation into the genetic factors for unrelated donor HCT and clinical implications of diverse ethnic background.
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Affiliation(s)
- Yasuo Morishima
- Japan Marrow Donor Program, Tokyo, Japan; Division of Epidemiology and Prevention, Aichi Cancer Center Research Institute, Nagoya, Japan.
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37
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Survival and prognostic factors in Malaysian acute myeloid leukemia patients after allogeneic haematopoietic stem cell transplantation. Int J Hematol 2013; 98:197-205. [DOI: 10.1007/s12185-013-1373-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 05/15/2013] [Accepted: 05/15/2013] [Indexed: 11/25/2022]
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38
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Zandberg DP, Hendrick F, Vannorsdall E, Bierenbaum J, Tidwell ML, Ning Y, Zhao XF, Davidoff AJ, Baer MR. Tertiary center referral patterns for patients with myelodysplastic syndrome are indicative of age and race disparities: a single-institution experience. Leuk Lymphoma 2013; 54:304-9. [PMID: 22793170 DOI: 10.3109/10428194.2012.710904] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Little is known about disparities in myelodysplastic syndromes (MDS). We performed a retrospective chart review of patients with MDS (n = 252) evaluated at the University of Maryland Greenebaum Cancer Center between 2000 and 2010. The median age at diagnosis was 65 years, which was lower than the median age of 76 years for patients with MDS in the Surveillance, Epidemiology and End Results database. Black males were younger than white males (62 vs. 68 years; p = 0.03) and had longer time to referral (9 vs. 1.5 months; p = 0.03), but black and white females did not differ in age or in time to referral. A difference in World Health Organization subtype classification was noted in black and white patients at diagnosis, but not at referral. There was no difference between all other pretreatment characteristics, treatment and survival by race. Our data suggest barriers to tertiary care referral for older patients and for black males.
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Affiliation(s)
- Dan P Zandberg
- University of Maryland Greenebaum Cancer Center, Baltimore, MD 21201, USA
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39
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Majhail NS, Nayyar S, Santibañez MEB, Murphy EA, Denzen EM. Racial disparities in hematopoietic cell transplantation in the United States. Bone Marrow Transplant 2012; 47:1385-90. [PMID: 22056642 PMCID: PMC3848311 DOI: 10.1038/bmt.2011.214] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 09/27/2011] [Indexed: 01/13/2023]
Abstract
Hematopoietic cell transplantation (HCT) is a highly specialized, expensive and resource-intense medical procedure that can be associated with racial disparities. We review the prevailing literature on racial disparities in HCT in the United States and describe areas for future research and interventions. We discuss the complexity of interpreting race as a biological and social determinant of disease in biomedical research, especially as it relates to HCT. In the United States, race is often a surrogate for socioeconomic, education and health insurance status. We also discuss some of the nuances to consider while reviewing the literature on racial disparities. Disparities by race exist in three areas related to HCT: donor availability, access to HCT and outcomes of HCT. African-Americans/Blacks have a lower likelihood of finding an unrelated donor. Race and ethnicity definitions are country-specific and reconciling race data can represent significant challenges to unrelated donor registries worldwide. African-Americans/Blacks do not have the same access to autologous and allogeneic HCT as Whites. Racial disparities in outcomes of HCT are more prevalent among allogeneic HCT than autologous HCT recipients. More research is required to understand the biological, social, cultural, medical and financial aspects of race that may influence access to HCT and survival after transplantation. Better understanding of racial disparities will minimize inequities, inform health policy, guide development of interventions targeted to eliminate disparities and ensure equitable access to HCT for all populations.
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Affiliation(s)
- N S Majhail
- National Marrow Donor Program, Minneapolis, MN 55413, USA.
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40
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Ballen KK, Klein JP, Pedersen TL, Bhatla D, Duerst R, Kurtzberg J, Lazarus HM, LeMaistre CF, McCarthy P, Mehta P, Palmer J, Setterholm M, Wingard JR, Joffe S, Parsons SK, Switzer GE, Lee SJ, Rizzo JD, Majhail NS. Relationship of race/ethnicity and survival after single umbilical cord blood transplantation for adults and children with leukemia and myelodysplastic syndromes. Biol Blood Marrow Transplant 2012; 18:903-12. [PMID: 22062801 PMCID: PMC3874400 DOI: 10.1016/j.bbmt.2011.10.040] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 10/25/2011] [Indexed: 12/15/2022]
Abstract
The relationship of race/ethnicity with outcomes of umbilical cord blood transplantation (UCBT) is not well known. We analyzed the association between race/ethnicity and outcomes of unrelated single UCBT for leukemia and myelodysplastic syndromes. Our retrospective cohort study consisted of 885 adults and children (612 whites, 145 blacks, and 128 Hispanics) who received unrelated single UCBT for leukemia and myelodysplastic syndromes between 1995 and 2006 and were reported to the Center for International Blood and Marrow Transplant Research. A 5-6/6 HLA-matched unit with a total nucleated cell count infused of ≥2.5 × 10(7)/kg was given to 40% white and 42% Hispanic, but only 21% black patients. Overall survival at 2 years was 44% for whites, 34% for blacks, and 46% for Hispanics (P = .008). In multivariate analysis adjusting for patient, disease, and treatment factors (including HLA match and cell dose), blacks had inferior overall survival (relative risk of death, 1.31; P = .02), whereas overall survival of Hispanics was similar (relative risk, 1.03; P = .81) to that of whites. For all patients, younger age, early-stage disease, use of units with higher cell dose, and performance status ≥80 were independent predictors of improved survival. Black patients and white patients infused with well-matched cords had comparable survival; similarly, black and white patients receiving units with adequate cell dose had similar survival. These results suggest that blacks have inferior survival to whites after single UCBT, but outcomes are improved when units with a higher cell dose are used.
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Affiliation(s)
- Karen K Ballen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA 02114, USA.
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41
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Longo DM, Louie B, Putta S, Evensen E, Ptacek J, Cordeiro J, Wang E, Pos Z, Hawtin RE, Marincola FM, Cesano A. Single-cell network profiling of peripheral blood mononuclear cells from healthy donors reveals age- and race-associated differences in immune signaling pathway activation. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2012; 188:1717-25. [PMID: 22246624 PMCID: PMC3517183 DOI: 10.4049/jimmunol.1102514] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A greater understanding of the function of the human immune system at the single-cell level in healthy individuals is critical for discerning aberrant cellular behavior that occurs in settings such as autoimmunity, immunosenescence, and cancer. To achieve this goal, a systems-level approach capable of capturing the response of the interdependent immune cell types to external stimuli is required. In this study, an extensive characterization of signaling responses in multiple immune cell subpopulations within PBMCs from a cohort of 60 healthy donors was performed using single-cell network profiling (SCNP). SCNP is a multiparametric flow cytometry-based approach that enables the simultaneous measurement of basal and evoked signaling in multiple cell subsets within heterogeneous populations. In addition to establishing the interindividual degree of variation within a broad panel of immune signaling responses, the possible association of any observed variation with demographic variables including age and race was investigated. Using half of the donors as a training set, multiple age- and race-associated variations in signaling responses in discrete cell subsets were identified, and several were subsequently confirmed in the remaining samples (test set). Such associations may provide insight into age-related immune alterations associated with high infection rates and diminished protection following vaccination and into the basis for ethnic differences in autoimmune disease incidence and treatment response. SCNP allowed for the generation of a functional map of healthy immune cell signaling responses that can provide clinically relevant information regarding both the mechanisms underlying immune pathological conditions and the selection and effect of therapeutics.
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“It doesn’t matter if you’re black or white”, does it? Leuk Res 2012; 36:127. [DOI: 10.1016/j.leukres.2011.10.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 10/28/2011] [Accepted: 10/29/2011] [Indexed: 11/22/2022]
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Bierenbaum J, Davidoff AJ, Ning Y, Tidwell ML, Gojo I, Baer MR. Racial differences in presentation, referral and treatment patterns and survival in adult patients with acute myeloid leukemia: a single-institution experience. Leuk Res 2011; 36:140-5. [PMID: 22112974 DOI: 10.1016/j.leukres.2011.10.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2011] [Revised: 10/16/2011] [Accepted: 10/19/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Disease presentation and outcomes differ by race in a number of malignancies, but data in adult acute myeloid leukemia (AML) are limited. MATERIALS AND METHODS We conducted a retrospective analysis of pretreatment characteristics, referral and treatment patterns, and outcomes in 548 AML patients evaluated at the University of Maryland Greenebaum Cancer Center, a tertiary care referral center in Baltimore, MD, from 2000 through 2009. Cases were analyzed for time from diagnosis to referral, age, race, gender, socioeconomic status, antecedent hematologic disorder, cytotoxic or radiation therapy for prior malignancy, karyotype, fms-like tyrosine kinase receptor-3 (FLT3) mutations, intensive chemotherapy, clinical trial participation, hematopoietic stem cell transplantation (HSCT) and overall survival (OS). RESULTS Black patients (n=105) were younger than white patients (n=396) (54 vs. 61 years, p<0.001), were more commonly female (55% vs. 45%, p<0.001), and had a lower estimated median household income ($42,677 vs. $53,534 per year, p<0.001). Black patients more frequently had complex karyotypes (26% vs. 12%, p=0.002) and less frequently normal karyotypes (27% vs. 42%, p=0.02). FLT3 mutation frequency was similar. Time to referral and proportion of patients receiving intensive chemotherapy did not differ, but both clinical trial participation (43% vs. 54%, p=0.04) and HSCT (17% vs. 35% for patients ≤70 years old, p=0.001) were less frequent in blacks than whites. Nevertheless, OS was similar in all black and white patients (median 15 vs. 14 months, p=0.23), and when stratified by age, gender and karyotype risk classification. CONCLUSION AML presentation and treatment differed in black and white patients, but OS was similar. Black patients appear to have barriers to clinical trial participation and HSCT, and there may be barriers to tertiary care referral for black males.
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Affiliation(s)
- Jason Bierenbaum
- University of Maryland Greenebaum Cancer Center, Baltimore, MD 21201, USA
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Deeg HJ, Sandmaier BM. Who is fit for allogeneic transplantation? Blood 2010; 116:4762-70. [PMID: 20702782 PMCID: PMC3253743 DOI: 10.1182/blood-2010-07-259358] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 08/07/2010] [Indexed: 11/20/2022] Open
Abstract
The use of allogeneic hematopoietic cell transplantation (HCT) has expanded progressively, facilitated by the increasing availability of unrelated donors and cord blood, and the inclusion of older patients as transplantation candidates. Indications remain diagnosis-dependent. As novel nontransplantation modalities have been developed concurrently, many patients come to HCT only when no longer responding to such therapy. However, patients with refractory or advanced disease frequently relapse after HCT, even with high-dose conditioning, and more so with reduced-intensity regimens as used for patients of older age or with comorbid conditions. Thus, patients with high-risk malignancies who have substantial comorbidities or are of advanced age are at high risk of both relapse and nonrelapse mortality and should probably not be transplanted. Being in remission or at least having shown responsiveness to pre-HCT therapy is generally associated with increased transplantation success. In addition, to handle the stress associated with HCT, patients need a good social support system and a secure financial net. They must be well informed, not only about the transplantation process, but also about expected or potential post-HCT events, including graft-versus-host disease and delayed effects that may become manifest only years after HCT.
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Affiliation(s)
- H Joachim Deeg
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA.
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Armenian SH, Sun CL, Teh JB, Arora M, Baker KS, Francisco L, Forman SJ, Bhatia S. Ethnic differences in chronic health conditions after hematopoietic cell transplantation: a report from the Bone Marrow Transplant Survivor Study. Cancer 2010; 116:4152-9. [PMID: 20564108 PMCID: PMC2930121 DOI: 10.1002/cncr.25157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hispanics have a greater risk of early treatment failure after hematopoietic stem cell transplantation (HCT) compared with non-Hispanic whites. However, long-term morbidity among Hispanics has not been described. METHODS Health-related outcomes were examined in 159 Hispanic patients and 825 non-Hispanic white patients who underwent HCT between 1974 and 1998 and survived a mean of 8.7 years. Patients completed a detailed questionnaire about sociodemographic factors and the occurrence of chronic health conditions. RESULTS Exposure to total body irradiation (TBI) (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.06-3.56; P = .03), the presence of chronic graft versus host disease (GvHD) (OR, 3.99; 95% CI, 1.94-8.24; P = .002), and health insurance coverage (OR, 3.46; 95% CI, 1.5-8.01; P = .004), were associated significantly with severe/life-threatening conditions. Compared with non-Hispanic white patients, Hispanic patients were 53% less likely to report severe/life-threatening conditions (OR, 0.47; 95% CI, 0.27-0.83; P = .009) after adjusting for relevant clinical variables. This effect size was mitigated (OR, 0.56; 95%CI, 0.29-1.08; P = .08) after adjusting for health insurance coverage. CONCLUSIONS Hispanics were less likely to report severe/life-threatening health conditions after HCT than non-Hispanic whites-a difference that decreased in magnitude and significance after taking health insurance into consideration. Although the current results confirmed the role of TBI and chronic GvHD, in the current study, the role of a lack of health insurance coverage was identified as a mediator of the lower prevalence of self-reported long-term morbidity in Hispanics.
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Affiliation(s)
- Saro H Armenian
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA 91010-3000, USA
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Loberiza FR, Lee SJ, Freytes CO, Giralt SA, Van Besien K, Kurian S, del Cerro P, Toro JJ, Williams LA, Ketelsen SW, Navarro WH, Rizzo JD. Methodological and logistical considerations to study design and data collection in racial/ethnic minority populations evaluating outcome disparity in hematopoietic cell transplantation. Biol Blood Marrow Transplant 2009; 15:903-9. [PMID: 19589479 DOI: 10.1016/j.bbmt.2009.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 04/07/2009] [Indexed: 11/16/2022]
Abstract
Outcome disparity associated with race or ethnicity in the United States has been observed in hematopoietic cell transplantation (HCT). The underlying reasons for such disparity are not known. In the United States, an optimal study of health care disparity by race or ethnicity involves consideration of both biologic and psychosocial determinants, which requires an adequately powered, prospective cohort study design. To better characterize the nature and quantify the magnitude of the many impediments relevant to conducting a successful prospective study involving racial or ethnic minorities in HCT, we conducted a feasibility study to help guide planning of a larger scale outcome and disparity study in HCT. The primary questions to be addressed in the study were: (1) can we establish a racially or ethnically diverse patient sample that will respond to a survey focused on sociodemographic, economic, health insurance, cultural, spiritual, and religious well-being, and social support information? (2) What is the retention rate in the study over time? (3) What is the quality of the data collected from the patients over time? The challenges we faced in conducting this multicenter feasibility study are summarized in this report. Despite the difficulty in conducting disparity studies in racial and ethnic minorities, such studies are essential to ensure that people of all ethnic and racial backgrounds have the best chance possible of benefiting from HCT.
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Affiliation(s)
- Fausto R Loberiza
- UNMC Onc/Hem Section, University of Nebraska Medical Center, Omaha, Nebraska 68198-7680, USA.
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Baker KS, Davies SM, Majhail NS, Hassebroek A, Klein JP, Ballen KK, Bigelow CL, Frangoul HA, Hardy CL, Bredeson C, Dehn J, Friedman D, Hahn T, Hale G, Lazarus HM, LeMaistre CF, Loberiza F, Maharaj D, McCarthy P, Setterholm M, Spellman S, Trigg M, Maziarz RT, Switzer G, Lee SJ, Rizzo JD. Race and socioeconomic status influence outcomes of unrelated donor hematopoietic cell transplantation. Biol Blood Marrow Transplant 2009; 15:1543-54. [PMID: 19896078 DOI: 10.1016/j.bbmt.2009.07.023] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 07/27/2009] [Indexed: 12/15/2022]
Abstract
Success of hematopoietic cell transplantation (HCT) can vary by race, but the impact of socioeconomic status (SES) is not known. To evaluate the role of race and SES, we studied 6207 unrelated-donor myeloablative (MA) HCT recipients transplanted between 1995 and 2004 for acute or chronic leukemia or myelodysplastic syndrome (MDS). Patients were reported by transplant center to be White (n = 5253), African American (n = 368), Asian/Pacific-Islander (n = 141), or Hispanic (n = 445). Patient income was estimated from residential zip code at time of HCT. Cox regression analysis adjusting for other significant factors showed that African American (but not Asian or Hispanic) recipients had worse overall survival (OS) (relative-risk [RR] 1.47; 95% confidence interval [CI] 1.29-1.68, P < .001) compared to Whites. Treatment-related mortality (TRM) was higher in African Americans (RR 1.56; 95% CI 1.34-1.83, P < .001) and in Hispanics (RR 1.30; 95% CI 1.11-1.51, P = .001). Across all racial groups, patients with median incomes in the lowest quartile (<$34,700) had worse OS (RR 1.15; 95% CI 1.04-1.26, P = .005) and higher risks of TRM (RR 1.21; 1.07-1.36, P = .002). Inferior outcomes among African Americans are not fully explained by transplant-related factors or SES. Potential other mechanisms such as genetic polymorphisms that have an impact on drug metabolism or unmeasured comorbidities, socioeconomic factors, and health behaviors may be important. Low SES, regardless of race, has a negative impact on unrelated donor HCT outcomes.
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Affiliation(s)
- K Scott Baker
- Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA.
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Schwake CJ, Eapen M, Lee SJ, Freytes CO, Giralt SA, Navarro WH, Rizzo JD, van Besien K, Loberiza FR. Differences in characteristics of US hematopoietic stem cell transplantation centers by proportion of racial or ethnic minorities. Biol Blood Marrow Transplant 2006; 11:988-98. [PMID: 16338621 DOI: 10.1016/j.bbmt.2005.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Accepted: 07/28/2005] [Indexed: 11/30/2022]
Abstract
Racial or ethnic minorities with leukemia who receive HLA-identical sibling hematopoietic stem cell transplants (HSCTs) are reported to have worse survival when compared with whites. Characteristics of US HSCT centers according to the proportion of ethnic minorities who undergo transplantation were compared to explore systematic differences among centers; the association with 100-day mortality was evaluated to determine whether center factors may explain the observed discrepant survival among ethnic minorities. One hundred sixteen US transplantation centers that performed HLA-identical sibling transplantations for leukemia were analyzed. We compared physician and health care provider staffing, transplantation unit procedure and resources, and medical center organization according to the volume procedure ratio of ethnic minorities who underwent transplantation and also according to the ratio of Hispanics who underwent transplantation. Centers that performed transplantation in a higher proportion of ethnic minorities were more likely to perform fewer transplantations per year, to have fewer devoted transplant beds, to be in an urban setting, to have a lower physician to patient volume ratio, and to follow up survivors 1 year after transplantation. Centers that performed transplantation in a higher proportion of Hispanics were more likely to perform fewer transplantations per year and to have fewer devoted transplantation beds, were less likely to perform outpatient transplantations, were more likely to be in an urban setting, and were less likely to have posttransplantation immunization protocols. Observed differences in center factors were not associated with 100-day mortality after adjustment for disease severity. Our results suggest that the inferior survival reported in ethnic minorities after HSCT may not be readily explained by center effects.
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Saraf S, Chen YH, Dobogai LC, Mahmud N, Peace D, Saunthararajah Y, Hoffman R, Chunduri S, Rondelli D. Prolonged responses after autologous stem cell transplantation in African-American patients with multiple myeloma. Bone Marrow Transplant 2006; 37:1099-102. [PMID: 16699527 DOI: 10.1038/sj.bmt.1705392] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Multiple myeloma (MM) has a double incidence in African-American (AA) than in non-AA patients and previous studies have shown a higher mortality in the former patient population. Here, we retrospectively analyzed the results of autologous stem cell transplantation (ASCT) in 38 AA and 32 non-AA consecutive patients. The two groups were comparable at diagnosis for age, stage of the disease, cytogenetic abnormalities, beta(2) microglobulin and albumin blood levels, and plasma cell marrow infiltration. The rates of complete and partial response observed in AA and non-AA patients after induction chemotherapy (9 and 42 vs 13 and 33%) and at 2 months (31 and 25 vs 30 and 20%) following ASCT were similar. At 6 months after ASCT, a greater relapse rate was observed in non-AA patients (P=0.009). At a median follow-up of 26 months, AA patients had a greater event-free survival (P=0.02) than non-AA patients, whereas overall survival was comparable in the two groups. The initial finding that AA patients with MM, compared to non-AA patients, had more prolonged responses and comparable survival after ASCT suggests that intensified chemotherapy is equally effective in patients of various ethnicities.
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Affiliation(s)
- S Saraf
- Section of Hematology/Oncology, University of Illinois at Chicago, 900 South Ashland Avenue, Chicago, IL 60607, USA
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