Racial and ethnic disparities in hematologic malignancies

Association between the IL1B-511 C>T polymorphism and the risk of hematologic malignancies: data from a meta-analysis

The relationship between the IL1B-511C>T (rs16944) polymorphism and the risk of developing hematologic malignancies remains controversial. Thus, we performed a meta-analysis to evaluate the association between IL1B-511C>T polymorphism and the risk of developing hematologic malignancies. A comprehensive search was conducted to identify all eligible studies on IL1B-511C>T polymorphism and hematologic malignancies. Twelve case-control studies, with 2,896 cases and 3,716 controls, were selected for the analysis. The overall data failed to indicate a significant association between IL1B-511C>T polymorphism and the risk of hematologic malignancies (OR:1.06, 95% Confidence Interval [CI]: 0.93-1.22). Moreover, non-significant associations were observed in a stratified analysis according to neoplasm type (multiple myeloma, Hodgkin's lymphoma, and non-Hodgkin's lymphoma), ethnicity (European and Asian), and Hardy-Weinberg equilibrium. In summary, our results suggest that there is no association between the IL1B-511C>T polymorphism and the risk of hematologic malignancies. As such, further large-scale studies are needed to confirm our findings.

Review of Baduanjin and resistance exercise for the mental health of patients with hematologic malignancies

Patients with hematological tumors experience physical and psychological stress, and negative psychological states. Baduanjin, an emerging psychological rehabilitation method combined with resistance exercise, has received widespread attention. This study reviews the current status of the application of Baduanjin combined with resistance exercise in improving the negative psychological state of patients with hematological tumors and discusses its problems and prospects. Through a literature review and comprehensive analysis, the application of Baduanjin and resistance exercise in the psychological rehabilitation of patients with hematological tumors was identified and evaluated. The results showed that Baduanjin with resistance exercise had a positive effect on improving negative psychological states of patients with hematological tumors, which can alleviate anxiety, depression, and other adverse emotions, and improve quality of life. However, there is a lack of unified and standardized exercise intervention programs for practical application, and patient participation and compliance must be improved. Baduanjin combined with resistance exercise can potentially improve the negative psychological status of patients with hematological tumors; however, it is still necessary to further standardize and improve the exercise program improving patient participation and compliance. Future studies should strengthen theoretical exploration and empirical research, providing more effective psychological rehabilitation strategies for patients with hematological tumors.

Trends in volumes and survival after hematopoietic cell transplantation in racial/ethnic minorities

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.

Multiple myeloma

Multiple myeloma (MM) is a haematological lymphoid malignancy involving tumoural plasma cells and is usually characterized by the presence of a monoclonal immunoglobulin protein. MM is the second most common haematological malignancy, with an increasing global incidence. It remains incurable because most patients relapse or become refractory to treatments. MM is a genetically complex disease with high heterogeneity that develops as a multistep process, involving acquisition of genetic alterations in the tumour cells and changes in the bone marrow microenvironment. Symptomatic MM is diagnosed using the International Myeloma Working Group criteria as a bone marrow infiltration of ≥10% clonal plasma cells, and the presence of at least one myeloma-defining event, either standard CRAB features (hypercalcaemia, renal failure, anaemia and/or lytic bone lesions) or biomarkers of imminent organ damage. Younger and fit patients are considered eligible for transplant. They receive an induction, followed by consolidation with high-dose melphalan and autologous haematopoietic cell transplantation, and maintenance therapy. In older adults (ineligible for transplant), the combination of daratumumab, lenalidomide and dexamethasone is the preferred option. If relapse occurs and requires further therapy, the choice of therapy will be based on previous treatment and response and now includes immunotherapies, such as bi-specific monoclonal antibodies and chimeric antigen receptor T cell therapy.

Racial and ethnic disparities in Acute Myeloid Leukemia: 15-year experience at a safety net hospital system

Despite recent therapeutic advances, ethnic minorities in the U.S. continue to have disproportionately poor outcomes in many hematologic malignancies including AML. We identified 162 adult AML patients treated at a non-transplant safety net hospital from 2007 to 2022 and evaluated differences in disease characteristics, treatment and clinical outcomes based on race and ethnicity. Our cohort consisted of 82 (50.6%) Hispanic, 36 (22.2%) non-Hispanic black and 44 (27.2%) non-Hispanic white and Asian patients. Median age at diagnosis was 42.5, 49.0 and 52.5 years respectively (p=0.025). Hispanics had higher rates of intermediate and high-risk disease (p=0.699) and received high intensity induction and consolidation chemotherapy at lower rates (p=0.962), although differences did not reach statistical significance. Despite this, similar remission rates were achieved. Hispanics with high-risk disease had longer overall survival (OS) than the combined non-Hispanic cohort (mOS 14 m vs 7 m, p=0.030). Multivariate regression analysis showed that OS was negatively associated with age (HR 1.023, p=0.006), intermediate (HR 3.431, p=0.0003) and high-risk disease (HR 4.689, p<0.0001) and positively associated with Hispanic ethnicity (HR 0.614, p=0.026). This report suggests that contrary to other studies, Hispanics, particularly those with high-risk AML, may have improved OS compared to other ethnic groups. These results are unique to our safety net hospital setting where common barriers to medical care and healthcare disparities are largely mitigated.

Evaluating Socioeconomic, Racial, and Ethnic Disparities in Survival Among Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplants

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.

Donor matters: Donor selection impact on hematopoietic stem cell transplantation outcomes in Hispanic patients with B-cell acute lymphocytic leukemia: Insights from a myeloablative HSCT study

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is a pivotal treatment for high-risk acute lymphocytic leukemia (ALL), although limited by suitable human leukocyte antigen (HLA)-matched sibling donors (MSD). This study evaluates the impact of donor selection on outcomes in post-HSCT Hispanic B-cell ALL patients.

METHODOLOGY

This single-center retrospective study evaluates outcomes in 88 adult Hispanic B-cell ALL patients who underwent haploidentical, MSD, or MUD myeloablative HSCT between 2013 and 2023.

RESULTS

Compared to Haploidentical transplants, MSD exhibited worse cumulative incidence of relapse (CIR) (HR = 3.39; P = 0.014) and disease-free survival (DFS) (HR = 2.44; P = 0.048) whereas MUD outcomes did not differ. This effect persisted even when controlling for pre-HSCT stage and Minimal residual disease (MRD) status. In addition, Ph-like was a significant predictor of worse DFS (HR = 3.60; P=0.014) and CIR (HR = 2.97; P=0.035) on multivariate analysis. Older donor age correlated with worse GVHD-free, relapse-free survival (GRFS) in haploidentical transplants (HR = 1.05; P=0.036).

CONCLUSION

Our data highlights improved outcomes with younger, haploidentical donors among Hispanic B-cell ALL patients undergoing myeloablative HSCT. This underscores the importance of donor selection in optimizing outcomes for ALL patients.

Racial Disparities in Cardiovascular and Cerebrovascular Adverse Events in Patients with Non-Hodgkin Lymphoma: A Nationwide Analysis

Background and Objectives: Non-Hodgkin lymphoma (NHL) has the sixth-highest malignancy-related mortality in the United States (US). However, inequalities exist in access to advanced care in specific patient populations. We aim to study the racial disparities in major adverse cardiovascular and cerebrovascular events (MACCEs) in NHL patients. Materials and Methods: Using ICD-10 codes, patients with NHL were identified from the US National Inpatient Sample 2016-2019 database. Baseline characteristics, comorbidities, and MACCE outcomes were studied, and results were stratified based on the patient's race. Results: Of the 777,740 patients with a diagnosis of NHL, 74.22% (577,215) were White, 9.15% (71,180) were Black, 9.39% (73,000) were Hispanic, 3.33% (25,935) were Asian/Pacific Islander, 0.36% (2855) were Native American, and 3.54% (27,555) belonged to other races. When compared to White patients, all-cause mortality (ACM) was significantly higher in Black patients (aOR 1.27, 95% CI 1.17-1.38, p < 0.001) and in Asian/Pacific Islander patients (aOR 1.27, 95% CI 1.12-1.45, p < 0.001). Sudden cardiac death was found to have a higher aOR in all racial sub-groups as compared to White patients; however, it was statistically significant in Black patients only (aOR 1.81, 95% CI 1.52-2.16, p < 0.001). Atrial fibrillation (AF) risk was significantly lower in patients who were Black, Hispanic, and of other races compared to White patients. Acute myocardial infarction (AMI) was noted to have a statistically significantly lower aOR in Black patients (0.70, 95% CI 0.60-0.81, p < 0.001), Hispanic patients (0.69, 95% CI 0.59-0.80, p < 0.001), and patients of other races (0.57, 95% CI 0.43-0.75, p < 0.001) as compared to White patients. Conclusions: Racial disparities are found in MACCEs among NHL patients, which is likely multifactorial, highlighting the need for healthcare strategies stratified by race to mitigate the increased risk of MACCEs. Further research involving possible epigenomic influences and social determinants of health contributing to poorer outcomes in Black and Asian/Pacific Islander patients with NHL is imperative.

Survival of adult AML patients treated with chemotherapy in the U.S. population by age, race and ethnicity, sex, calendar-year period, and AML subgroup, 2001-2019

Background

Population-based survival studies of adult acute myeloid leukemia (AML) have not simultaneously evaluated age at diagnosis, race and ethnicity, sex, calendar period or AML subtypes/subgroups among chemotherapy-treated patients.

Methods

For 28,473 chemotherapy-treated AML patients diagnosed at ages ≥20 years in population-based cancer registry areas of the Surveillance, Epidemiology, and End Results Program (2001-2018, followed through 2019), we evaluated 1-month through 5-year relative survival (RS) and 95% confidence intervals (95% CI) using the actuarial method in the SEER∗Stat Survival Session and overall survival (OS) using multivariable Cox regression to estimate proportional hazard ratios (HR) and 95% CI.

Findings

RS decreased with increasing age (20-39, 40-59, 60-74, 75-84, ≥85 years) at AML diagnosis. RS declined substantially within the first month and, except for acute promyelocytic leukemia, decreasing patterns continued thereafter for core binding factor AML, AML with antecedent condition/therapy, and all other AML. For all ages, acute promyelocytic leukemia RS stabilized after the first year. For total AML the hazard of death was significantly increased for non-Hispanic (NH)-Black (HR = 1.18, 95% CI = 1.12-1.24) and NH-Pacific Islander patients (HR = 1.31, 95% CI = 1.11-1.55) compared with NH-White patients. In contrast, NH-Asian and Hispanic patients had similar OS to NH-White patients across all ages and most AML subgroups. Males had significantly inferior survival to females with some exceptions. Compared to 2001-2006, in 2013-2018 OS improved for all age and AML subgroups.

Interpretation

Chemotherapy-treated U.S. adults with AML have notable differences in survival by age, race and ethnicity, sex, calendar-year period, and AML subgroup. Despite survival gains over time, our findings highlight the need for improving early outcomes across all AML subgroups, older ages, and Black and Pacific Islander patients and long-term outcomes among most treated groups.

Funding

Intramural Research Program of the U.S. National Institutes of Health, National Cancer Institute, Division of Cancer Epidemiology and Genetics, and the U.S. Food and Drug Administration, Center for Drug Evaluation and Research, Office of Surveillance and Epidemiology.

Disparity in hematological malignancies: From patients to health care professionals

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.

Multiple myeloma incidence, mortality, and survival differences at the intersection of sex, age, and race/ethnicity: A comparison between Puerto Rico and the United States SEER population

BACKGROUND

Multiple myeloma (MM) survival has increased during the last decades due to the introduction of new therapies. We investigated the intersectionality among age, sex, and race/ethnicity to better understand the pattern of MM incidence, mortality, and survival.

METHODS

Puerto Rico (PR) Central Cancer Registry and the United States of America (US) Surveillance, Epidemiology, and End Results (SEER) Program databases were used. We analyzed MM incidence and mortality trends from 2001 to 2019 using Joinpoint regression models to calculate annual percent change (APC). Age-standardized rate ratios (SRR) for incidence and mortality were used to compare PR with US SEER racial/ethnic groups during 2015-2019. Five-year survival analyses were also performed stratified by age and sex.

RESULTS

Regardless of age and race/ethnicity, males had higher MM incidence and mortality rates than females. PR had a higher increase in incidence rates of MM than other ethnic groups, regardless of sex and age (PR APC = 4.3 among males <65, 3.1 among males ≥65, 6.3 among females <65, and 2.6 among females ≥65 years old). No significant change in mortality APCs (p > 0.05) was observed in PR when stratified by age or sex while other groups showed a decrease. Among males < 65 years, PR had significantly higher incidence rates than non-Hispanic Whites (NHW), and US Hispanics (USH). However, among both males and females ≥ 65 years, PR had significantly lower MM mortality rates than NHW, non-Hispanic Blacks (NHB), USH, and US Overall. In terms of survival, PR showed the lowest 5-year overall survival among males < 65 years (54.6%, 95% CI: 47.2-61.5) and males ≥ 65 years (34.5%, 95% CI: 29.2-39.9) but not among females.

CONCLUSION

The incidence of MM in PR increased significantly over the study period, particularly among younger women. Despite the introduction of new therapies, mortality rates in PR have remained stable while other ethnic groups show significant decreases among all intersections of sex and age.

Population-enriched innate immune variants may identify candidate gene targets at the intersection of cancer and cardio-metabolic disease

Both cancer and cardio-metabolic disease disparities exist among specific populations in the US. For example, African Americans experience the highest rates of breast and prostate cancer mortality and the highest incidence of obesity. Native and Hispanic Americans experience the highest rates of liver cancer mortality. At the same time, Pacific Islanders have the highest death rate attributed to type 2 diabetes (T2D), and Asian Americans experience the highest incidence of non-alcoholic fatty liver disease (NAFLD) and cancers induced by infectious agents. Notably, the pathologic progression of both cancer and cardio-metabolic diseases involves innate immunity and mechanisms of inflammation. Innate immunity in individuals is established through genetic inheritance and external stimuli to respond to environmental threats and stresses such as pathogen exposure. Further, individual genomes contain characteristic genetic markers associated with one or more geographic ancestries (ethnic groups), including protective innate immune genetic programming optimized for survival in their corresponding ancestral environment(s). This perspective explores evidence related to our working hypothesis that genetic variations in innate immune genes, particularly those that are commonly found but unevenly distributed between populations, are associated with disparities between populations in both cancer and cardio-metabolic diseases. Identifying conventional and unconventional innate immune genes that fit this profile may provide critical insights into the underlying mechanisms that connect these two families of complex diseases and offer novel targets for precision-based treatment of cancer and/or cardio-metabolic disease.

Access to cancer clinical trials for racialised older adults: an equity-focused rapid scoping review protocol

BACKGROUND

The intersection of race and older age compounds existing health disparities experienced by historically marginalised communities. Therefore, racialised older adults with cancer are more disadvantaged in their access to cancer clinical trials compared with age-matched counterparts. To determine what has already been published in this area, the rapid scoping review question are: what are the barriers, facilitators and potential solutions for enhancing access to cancer clinical trials among racialised older adults?

METHODS

We will use a rapid scoping review methodology in which we follow the six-step framework of Arksey and O'Malley, including a systematic search of the literature with abstract and full-text screening to be conducted by two independent reviewers, data abstraction by one reviewer and verification by a second reviewer using an Excel data abstraction sheet. Articles focusing on persons aged 18 and over who identify as a racialised person with cancer, that describe therapies/therapeutic interventions/prevention/outcomes related to barriers, facilitators and solutions to enhancing access to and equity in cancer clinical trials will be eligible for inclusion in this rapid scoping review.

ETHICS AND DISSEMINATION

All data will be extracted from published literature. Hence, ethical approval and patient informed consent are not required. The findings of the scoping review will be submitted for publication in a peer-reviewed journal and presentation at international conferences.

Temporal trend in survival for chronic myelomonocytic leukemia in the US: a population-based study

Outcomes for chronic myelomonocytic leukemia (CMML) are insufficiently characterized at the population level. We analyzed epidemiological trends for patients between 2001 and 2017, focusing on age, sex, race, and long-term survivors. Using the Surveillance, Epidemiology, and End Results Program, we studied 3929 patients, in four time-period (tp) cohorts, based on year of diagnosis [2001-2004 (tp1); 2005-2009 (tp2); 2010-2013 (tp3); 2014-2017 (tp4)]. Stable incidence overall, male predominance, and higher incidence for White versus Black and 'Other' races were noted. Three-year relative survival (RS) increased from 27.9% to 36.9% between tp1 and tp4. The most pronounced increase occurred between tp1 and tp2. All subgroups generally experienced RS improvements over time, except notably Black patients. Improvements for patients aged 85+ (3-year RS 8.4-23.6% between tp1 and tp4) and increases in long-term survivors (5-year OS from 13.2-22.3%) were observed. Additional study is warranted to explore these associations, particularly for Black patients.

Opportunities, challenges, and future directions for simulation modeling the effects of structural racism on cancer mortality in the United States: a scoping review

PURPOSE

Structural racism could contribute to racial and ethnic disparities in cancer mortality via its broad effects on housing, economic opportunities, and health care. However, there has been limited focus on incorporating structural racism into simulation models designed to identify practice and policy strategies to support health equity. We reviewed studies evaluating structural racism and cancer mortality disparities to highlight opportunities, challenges, and future directions to capture this broad concept in simulation modeling research.

METHODS

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension guidelines. Articles published between 2018 and 2023 were searched including terms related to race, ethnicity, cancer-specific and all-cause mortality, and structural racism. We included studies evaluating the effects of structural racism on racial and ethnic disparities in cancer mortality in the United States.

RESULTS

A total of 8345 articles were identified, and 183 articles were included. Studies used different measures, data sources, and methods. For example, in 20 studies, racial residential segregation, one component of structural racism, was measured by indices of dissimilarity, concentration at the extremes, redlining, or isolation. Data sources included cancer registries, claims, or institutional data linked to area-level metrics from the US census or historical mortgage data. Segregation was associated with worse survival. Nine studies were location specific, and the segregation measures were developed for Black, Hispanic, and White residents.

CONCLUSIONS

A range of measures and data sources are available to capture the effects of structural racism. We provide a set of recommendations for best practices for modelers to consider when incorporating the effects of structural racism into simulation models.

Survival of U.S. Military Service Members With Lymphoma

INTRODUCTION

Cancer is a prominent cause of mortality in today's active duty service members (ADSMs), killing over 700 ADSMs between 2004 and 2015. Hence, more research is needed to better understand the survival of U.S. service members with cancer. Lymphoma is the most common hematologic malignancy diagnosed in ADSMs, serving as a good cancer type to study.

MATERIALS AND METHODS

The Department of Defense tumor registry and the Surveillance, Epidemiology, and End Result (SEER) databases were retrospectively accessed to analyze overall survival (OS) of ADSMs with lymphoma and to compare outcomes with matched civilians. ADSMs with Hodgkin lymphoma (HL), diffuse large B-cell lymphoma (DLBCL), and indolent lymphoma diagnosed between 1997 and 2017 were included, and SEER comparator patients were matched by age, sex, race, stage, and year of diagnosis using a 4:1 ratio of civilians to ADSMs.

RESULTS

There were 1,170, 443, and 284 ADSMs with HL, DLBCL, and indolent lymphoma, respectively, and all three groups had superior OS when compared to their matched civilian counterparts with 35%, 49%, and 48% reductions in the risk of death, respectively. There were no differences in ADSM survival based on race, sex, or rank, despite disparities being pervasive in the civilian sector.

CONCLUSIONS

Service members with lymphoma have superior survival than their matched civilian counterparts, without evident racial or sex disparities. Results of this study are favorable in terms of readiness. Further research on cancer mortality in ADSMs is needed to improve long-term outcomes.

Lessons to inform interventions to reduce racial and ethnic health disparities within hematologic malignancies

Although racial and ethnic disparities in diagnosis, treatment, and survival have been well documented within the field of hematologic malignancies, very little work has focused on testing interventions that may reduce these disparities. The aim of this commentary is to review prior work in hematologic malignancies and explore new opportunities to develop disparity-reducing interventions by drawing from evidence-based strategies that have been successfully implemented in fields related to hematologic malignancies, including oncology and solid organ transplants. Relevant literature demonstrates that patient navigation and broader insurance coverage have been shown to reduce racial and ethnic disparities among patients with solid malignancies such as colorectal and breast cancer. Evidence-based strategies that might be most applicable to the field of hematologic malignancies include patient navigation and policy changes.

Stem Cell Transplant Experiences Among Hispanic/Latinx Patients: A Qualitative Analysis

BACKGROUND

Hispanic/Latinx (H/L) patients with cancer treated with stem cell transplant are vulnerable to adverse outcomes, including higher mortality. This study explored their unmet transplant needs, barriers, and facilitators.

METHODS

Eighteen English- or Spanish-speaking H/L patients (M age = 59.2) who had a transplant in the past year were interviewed about their transplant experience and rated their interest in receiving information about transplant topics (0 = not at all to 10 = extremely).

RESULTS

Content analysis revealed five main themes: (1) pre-transplant barriers and concerns; (2) complex relationships with medical teams; (3) informational mismatch; (4) impacts on daily life after transplant; and (5) methods of coping. Participants were most interested in information about ways of coping with transplant (M = 9.11, SD = 1.45) and words of hope and encouragement (M = 9.05, SD = 1.80). At just above the scale's midpoint, they were least interested in information about side effects and unintended consequences of transplant (M = 5.61, SD = 3.85).

CONCLUSIONS

Cultural factors, social determinants, and structural inequalities give rise to unique needs in this growing patient population. Healthcare team members and researchers can better meet the needs of H/L transplant recipients through attention to described considerations, such as financial barriers, communication difficulties, family dynamics, and coping styles.

Economic burden during remission and after relapse among older patients with newly diagnosed acute myeloid leukemia without hematopoietic stem cell transplant: A retrospective study using the SEER-Medicare database

Acute myeloid leukemia (AML) is associated with a substantial clinical and economic burden. This study characterized the magnitude of this burden following initial treatment with standard or less intensive therapies (hypomethylating agents [HMAs]) and throughout different treatment phases post-remission. The Surveillance, Epidemiology, and End Results (SEER) cancer registry (2007-2016) linked with Medicare beneficiary claims (2007-2015) was analyzed. Patients were ≥ 65 years old with AML who initiated chemotherapy or HMAs and achieved remission. Outcomes included baseline characteristics, treatment patterns, clinical outcomes, healthcare resource utilization (HRU), and costs (2019 United States dollar). Economic impacts were stratified by treatment phase (initial treatment, early post-remission, late post-remission, and post-relapse). Early and late post-remission were defined as treatment initiated ≤ 60 days and > 60 days following initial treatment, respectively. A subgroup analysis of patients receiving only HMAs as initial treatment was also conducted. Overall, 530 patients were included (mean age: 74.1 years; 53.6 % male). In the overall analysis, 68.1 % of patients received post-remission treatment; 31.9% had no post-remission treatment. Mean monthly per patient healthcare costs by treatment phase were $45,747 (initial treatment), $30,248 (early post-remission), $23,173 (late post-remission), and $37,736 (post-relapse), driven predominantly by inpatient visits. The HMA subgroup analysis comprised 71 patients (mean age: 78.8 years; 50.7 % male); mean monthly per patient healthcare costs were highest post-relapse. The economic burden of AML among older patients is substantial across all treatment phases. AML treatments that induce and prolong remission may reduce HRU and the economic burden of disease.

Therapy-related myeloid neoplasm in early breast cancer patients treated with adjuvant chemotherapy

BACKGROUND

Long-term complications are becoming more important as the survival rate of breast cancer improves. Treatment-related myeloid neoplasm is an important long-term complication in breast cancer survivors as it has a poor prognosis.

OBJECTIVE

We evaluated the incidence and risk factors for the development of treatment-related acute myeloid leukaemia (AML)/myelodysplastic syndrome (MDS) in patients treated with early breast cancer.

METHODS

We accessed the national Korean database to identify 153,565 patients diagnosed with breast cancer between January 2007 and October 2016 who underwent surgery for breast cancer. We estimated the cumulative incidence of AML/MDS and analysed the risk factors for developing AML/MDS.

RESULTS

Of 153,575 patients, 79,321 received anthracycline-based adjuvant therapy, 14,317 received adjuvant therapy without anthracyclines and 46,657 did not receive adjuvant chemotherapy. Overall, 120 developed AML (105 in the anthracycline group, 9 in the non-anthracycline group and 6 in the control group), and 128 developed MDS (96, 9 and 23 in each group). The 10-year cumulative incidence of AML/MDS was the highest in the anthracycline group (0.221% and 0.199%), followed by the non-anthracycline group (0.122% and 0.163%) and the control group (0.024% and 0.089%). The risk of developing AML/MDS was significantly higher in patients treated with anthracyclines (hazard ratio [HR] 9.531; p < 0.0001 for AML and HR 2.559; p < 0.0001 for MDS) compared to patients in the control group.

CONCLUSION

This study found that anthracycline-based adjuvant therapy significantly increased the risk of AML/MDS in Korean breast cancer patients, with the risk persisting for at least 10 years. While the cumulative incidence was low, the long-term risks of AML/MDS should be taken into account considering the poor outcomes associated with these neoplasms.

Incidence and Mortality Rates for Childhood Acute Lymphoblastic Leukemia in Puerto Rican Hispanics, 2012-2016

BACKGROUND

Acute lymphoblastic leukemia (ALL) accounts for 80% of all leukemias diagnosed in children. Although ALL age patterns are consistent across racial/ethnic groups, their incidence and mortality rates are highly variable. We assessed the age-standardized ALL incidence and mortality rates of Puerto Rican Hispanic (PRH) children and compared them with those of US mainland Hispanics (USH), non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), and Non-Hispanic Asian or Pacific Islanders (NHAPI).

METHODS

Differences between racial/ethnic groups were assessed by estimating the standardized rate ratio (SRR) for 2010 to 2014. Secondary data analyses of the Puerto Rico Central Cancer Registry and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) databases were performed for the 2001 to 2016 period.

RESULTS

PRH children had 31% lower incidence rates than USH, but 86% higher incidence rates than NHB. In addition, the incidence trends of ALL increased significantly from 2001 to 2016 among PRH and USH, with 5% and 0.9% per year, respectively. Moreover, PRH have a lower 5-year overall survival (81.7%) when compared with other racial/ethnic groups.

CONCLUSIONS

PRH children were found to have disparities in ALL incidence and mortality rates compared with other racial/ethnic groups in the US. Additional research is warranted to identify the genetic and environmental risk factors that may be associated with the disparities observed.

IMPACT

This is the first study reporting the incidence and mortality rates of childhood ALL for PRH and making comparisons with other racial/ethnic groups in the US. See related commentary by Mejía-Aranguré and Núñez-Enríquez, p. 999.

Association of killer cell immunoglobulin-like receptors and their cognate HLA class I ligands with susceptibility to acute myeloid leukemia in Iranian patients

Acute myeloid leukemia (AML) is one of the most prevalent leukemia in adults. Among the various NK receptors, killer immunoglobulin-like receptors (KIRs) carry out indispensable roles in NK cell development and function through engaging with class I human leukocyte antigens (HLA-I) as their ligands. Besides divergent KIR and HLA loci, KIR/HLA-I combinations have a significant effect on NK cell response. In this case-control study, we aimed to verify the association of KIR/HLA-I combinations with susceptibility to AML in the Southwestern Iranian population. KIR and HLA genotyping was performed with PCR-SSP by some novel primers for 181 patients with AML and 181 healthy controls. According to our results, the frequencies of KIR3DS1 (p = 0.0001, OR = 2.32, 95% CI 1.51-3.58), KIR2DS4fl (p = 0.02, OR = 1.53, 95% CI 1.05-2.21), CxT4 genotypes (p = 0.03, OR = 2.0, 95% CI 1.05-3.82), and T4 gene cluster (p = 0.01, OR = 1.99, 95% CI 1.17-3.41) were significantly higher in patients than controls, while C1/C2 genotype (p = 0.00002, OR = 0.39, 95% CI 0.25-0.61), HLA-A Bw4 (p = 0.02, OR = 0.6, 95% CI 0.38-0.94), and HLA-A*11 (p = 0.03, OR = 0.57, 95% CI 0.34-0.95) alleles were more frequent in controls. In addition, inhibitory (i)KIR/HLA-I combinations analysis revealed higher frequencies of KIR2DL1( +)/HLA-C2( +), KIR2DL2/3( +)/HLA-C1( +), KIR3DL1( +)/HLA-A Bw4( +), and KIR3DL2( +)/HLA-A*03/11( +) in the control group (p = 0.002, OR = 0.49, 95% CI 0.3-0.78; p = 0.04, OR = 0.62, 95% CI 0.39-0.99; p = 0.04, OR = 0.63, 95% CI 0.4-0.99; and p = 0.03, OR = 0.62, 95% CI 0.4-0.95, respectively). Overall, the number of iKIR/HLA-I combinations was more in the control group. Moreover, KIR3DS1( +)/HLA-B Bw4Ile80( +) and the sum of HLA-B Bw4/A Bw4 combined with KIR3DS1 as activating KIR/HLA-I combinations were more frequent among patients than controls (p = 0.01, OR = 1.99, 95% CI 1.14-3.49 and p = 0.005, OR = 1.97, 95% CI 1.22-3.19, respectively). In conclusion, our results postulate that inhibitory combinations play a protective role against AML by developing potent NK cells during education. It is noteworthy that KIR/HLA-I combination studies can be applicable in donor selection for allogeneic NK cell therapy in hematological malignancies.

Access to Chimeric Antigen Receptor T Cell Clinical Trials in Underrepresented Populations: A Multicenter Cohort Study of Pediatric and Young Adult Acute Lymphobastic Leukemia Patients

Chimeric antigen receptor T cell (CAR-T) therapy is a promising approach to improve survival for children and adults with relapsed/refractory (r/r) B cell acute lymphoblastic leukemia (B-ALL), but these clinical trials might not be equally accessible to patients of low socioeconomic status (SES) or to patients from racial or ethnic minority groups. We sought to describe the sociodemographic characteristics of pediatric and adolescent and young adult (AYA) patients enrolled in CAR-T clinical trials and to compare these characteristics to those of other patients with r/r B-ALL. We conducted a multicenter retrospective cohort study at 5 pediatric consortium sites to compare the sociodemographic characteristics of patients treated and enrolled in CAR-T trials at their home institution, other patients with r/r B-ALL treated at these sites, and patients referred from an external hospital for CAR-T trials. The patients were age 0 to 27 years with r/r B-ALL treated at 1 of the consortium sites between 2012 and 2018. Clinical and demographic data were collected from the electronic health record. We calculated distance from home to treating institution and assigned SES scores based on census tract. Among the 337 patients treated for r/r B-ALL, 112 were referred from an external hospital to a consortium site and enrolled in a CAR-T trial and 225 were treated primarily at a consortium site, with 34% enrolled in a CAR-T trial. Patients treated primarily at a consortium site had similar characteristics regardless of trial enrollment. Lower proportions of Hispanic patients (37% versus 56%; P = .03), patients whose preferred language was Spanish (8% versus 22%; P = .006), and publicly insured patients (38% versus 65%; P = .001) were referred from an external hospital than were treated primarily at a consortium site and enrolled in a CAR-T trial. Patients who are Hispanic, Spanish-speaking, or publicly insured are underrepresented in referrals from external hospitals to CAR-T centers. External provider implicit bias also may influence referral of these patients. Establishing partnerships between CAR-T centers and external hospital sites may improve provider familiarity, patient referral, and patient access to CAR-T clinical trials.

Comparison of demographics, disease characteristics, and outcomes between Black and White patients with myelodysplastic syndromes: A population-based study

Racial disparities in cancer care and outcomes have been well documented in various malignancies, with Black patients having the highest death rate and shortest survival of any racial/ethnic group in the United States (US) for most cancers. However, there have been limited studies on racial/ethnic disparities in myelodysplastic syndromes (MDS). Our study characterized and compared differences in baseline demographics, clinical characteristics, socioeconomic factors, and overall survival (OS) between Black and White patients with MDS in the US. We used the Surveillance, Epidemiology, and End Results (SEER) Program and included 37,562 patients (Black, 8.1 %; White, 91.9 %) diagnosed between 2001 and 2013. We observed significant differences in baseline characteristics between cohorts. In a univariate analysis, Black race was associated with longer survival (hazard ratio [HR]: 0.83; 95 % confidence interval [CI], 0.79-0.86; p < 0.001). The association between race and survival was attenuated but remained significant in various models to adjust for differences in baseline characteristics (HR in multivariable analysis, 0.92; 95 % CI, 0.87-0.96); p < 0.001). Subgroup analysis by histology revealed differences in the association between race and OS. Refractory anemia (RA), RA with ring sideroblasts, and MDS-not otherwise specified, a category in SEER representing a poorly defined MDS subset for 52 % of cases in our study, favored Black patients. RA with excess blasts favored White patients. The overall finding that Black race is associated with better OS outcomes, when compared with White patients, needs to be interpreted with caution and nuanced by histology. Additional research to explore these associations is warranted.

Disparities in mortality among acute myeloid leukemia-related hospitalizations

Racial and socioeconomic disparities have become apparent in acute myeloid leukemia (AML) outcomes. We conducted a retrospective cohort study of hospitalizations for adults with a diagnosis of AML from 2009 to 2018 in the Nationwide Inpatient Sample (NIS). We categorized patients' ages in groups of <60 years and ≥60 years and stratified them by reported race/ethnicity. Exposures of interest were patient sociodemographics, hospital characteristics, and Elixhauser-comorbidity Index. Outcome of interest was in-hospital death. Statistical analyses included survey logistic regression to generate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to quantify the independent associations between patient characteristics and mortality. Of 622,417 AML-related hospitalizations, 57.6% were in patients ≥60 years. The overall rate of in-hospital death was 9.4%. Compared to patients <60, older patients experienced a higher rate of in-hospital death. In both age groups and in all ethnicities, mortality decreased over time. Differences in mortality were observed based on gender, payer, hospital location, and teaching status. For hospitalizations in patients ≥60, NH-Black race was associated with inferior in-hospital death outcomes (OR 1.17; CI 1.08-1.28). Urban teaching hospitals were associated with a 38% increase (OR 1.38; CI 1.06-1.80) in inpatient mortality in patients <60 and a 15% decrease (OR 0.85; CI 0.77-0.95) in inpatient mortality in patients ≥60. Our results highlight the increased need to recognize the role of race/ethnicity and socioeconomic factors and their contribution to disparate outcomes in AML.

Multisite Quality Improvement Initiative to Identify and Address Racial Disparities and Deficiencies in Delivering Equitable, Patient-Centered Care for Multiple Myeloma-Exploring the Differences between Academic and Community Oncology Centers

Treatment of multiple myeloma (MM) is complex; however, with equal access to care, clinical outcomes for Black patients match those in other patient groups. To reveal and begin to address clinical practice barriers to equitable, patient-centered MM care, this quality improvement (QI) initiative assessed patient electronic medical records (EMRs) and surveyed patients and providers at two large hospital systems and four community-based practices. For the educational intervention, providers participated in feedback-focused grand rounds sessions to reflect on system barriers and develop action plans to improve MM care. EMR reviews revealed infrequent documentation of cytogenetics and disease staging at community-based practices compared to large hospital systems. In surveys, providers from each care setting reported different challenges in MM care. Notably, the goals of treatment for patients and providers aligned at community clinics while providers and patients from large hospital systems had discordant perspectives. However, providers in community settings underreported race-associated barriers to care and identified different factors impacting treatment decision-making than Black patients. Relative to pre-session responses, providers were more likely to report high confidence after the educational sessions in aligning treatment decisions with guidelines and clinical evidence and shared decision-making (SDM). This QI study identified discordant perceptions among providers at large hospital systems and community-based practices in providing quality MM care. Provider education yielded increased confidence in and commitment to patient-centered care.

A Pediatric Case of Treatment-related Myelodysplastic Syndrome While on Therapy for Pre-B Acute Lymphoblastic Leukemia

BACKGROUND

Treatment-related myelodysplastic syndrome (t-MDS) is a rare late effect of cancer therapy. After alkylating agents, this typically occurs years after completion of therapy. Treatment of t-MDS in pediatrics is an allogeneic stem cell transplant, however, the prognosis remains poor.

OBSERVATIONS

This case demonstrates t-MDS developing in a patient receiving treatment for pre-B acute lymphoblastic leukemia. This patient was treated with a combination of hematopoietic stem cell transplant and hypomethylating agents.

CONCLUSIONS

These agents should be considered for use in patients with t-MDS, before transplant to limit additional chemotherapy and as maintenance therapy post-transplant to reduce the risk of relapse.

Race and ethnicity: Risk factors for fungal infections?

Racial and ethnic identities, largely understood as social rather than biologic constructs, may impact risk for acquiring infectious diseases, including fungal infections. Risk factors may include genetic and immunologic differences such as aberrations in host immune response, host polymorphisms, and epigenomic factors stemming from environmental exposures and underlying social determinants of health. In addition, certain racial and ethnic groups may be predisposed to diseases that increase risk for fungal infections, as well as disparities in healthcare access and health insurance. In this review, we analyzed racial and ethnic identities as risk factors for acquiring fungal infections, as well as race and ethnicity as they relate to risk for severe disease from fungal infections. Risk factors for invasive mold infections such as aspergillosis largely appear related to environmental differences and underlying social determinants of health, although immunologic aberrations and genetic polymorphisms may contribute in some circumstances. Although black and African American individuals appear to be at high risk for superficial and invasive Candida infections and cryptococcosis, the reasons for this are unclear and may be related to underling social determinants of health, disparities in access to healthcare, and other socioeconomic disparities. Risk factors for all the endemic fungi are likely largely related to underlying social determinants of health, socioeconomic, and health disparities, although immunologic mechanisms likely play a role as well, particularly in disseminated coccidioidomycosis.

Sociodemographic Disparities in Access to Cleft Rhinoplasty

Various sociodemographic factors affect patient access to care. This study aims to assess how factors such as government-funded insurance and socioeconomic status impact the ability of adolescents with cleft lip-associated nasal deformities to access secondary rhinoplasty procedures. Patients older than 13 years old with a history of cleft lip/palate were identified in the National Inpatient Sample database from 2010 to 2012. Those who received a secondary rhinoplasty were identified using the International Classification of Diseases, Ninth Revision (ICD-9) procedural codes. A multivariate logistic regression model with post hoc analyses was performed to analyze if insurance status, socioeconomic status, and hospital-level variables impacted the likelihood of undergoing rhinoplasty. Of the 874 patients with a cleft lip/palate history, 154 (17.6%) underwent a secondary rhinoplasty. After controlling for various patient-level and hospital-level variables, living in a higher income quartile (based on zip code of residence) was an independent predictor of receiving a secondary cleft rhinoplasty (odds ratio=1.946, P =0.024). Patients had lower odds of receiving a cleft rhinoplasty if care occurred in a private, nonprofit hospital compared with a government-owned hospital (odds ratio=0.506, P =0.030). Income status plays a significant role in cleft rhinoplasty access, with patients from lower income households less likely to receive a secondary cleft rhinoplasty. Hospital-specific factors such as geographic region, bed size, urbanization, and teaching status may also create barriers for patients and their families in accessing surgical care for cleft lip nasal deformities.

Racial/ethnic disparities for leukemias in Puerto Rico and the United States of America, 2015-2019

BACKGROUND

Leukemia is a cancer of the early-forming cells. Over the past decade, leukemia racial/ethnic disparities have been documented in the United States of America (USA). Although the Puerto Rican population in the USA represents the second-largest Hispanic population in the nation, most of the existing studies do not include Puerto Rico. We compared the incidence and mortality rates for leukemia and its subtypes in Puerto Rico and four racial/ethnic groups in the USA.

METHODS

We used data from the Puerto Rico Central Cancer Registry and the Surveillance, Epidemiology, and End Results Program (2015-2019). The racial/ethnic groups studied were non-Hispanic whites (NHW), non-Hispanic blacks (NHB), Hispanics (USH), and Asian/Pacific Islanders (NHAPI) living in the USA and the Puerto Rico population. We calculated the incidence and mortality rates. The relative risk of developing or dying due to leukemia was also calculated.

RESULTS

Compared with Puerto Rico, NHW [standardized incidence rate (SIR) = 1.47; 95%CI = 1.40-1.53; standardized mortality rates (SMR) = 1.55; 95%CI = 1.45-1.65)] and NHB (SIR = 1.09; 95%CI = 1.04-1.15; SMR = 1.27; 95%CI = 1.19-1.35) had higher incidence and mortality rates; but lower than the NHAPI (SIR = 0.78; 95%CI = 0.74-0.82; SMR = 0.83; 95%CI = 0.77-0.89); and similar to USH. However, we found differences among leukemia subtypes. For example, NHAPI and USH had lower risk of developing chronic leukemias than Puerto Rico. We found a lower risk to develop acute lymphocytic leukemia in NHB than in Puerto Rico.

CONCLUSIONS

Our study provides a better understanding of leukemia's racial/ethnic disparities and fills a knowledge gap by examining the incidence and mortality rates in Puerto Rico. Future studies are needed to better understand the factors influencing the differences found in the incidence and mortality of leukemia among different racial/ethnic groups.

Sex differences in adults with acute myeloid leukemia and the impact of sex on overall survival

BACKGROUND

There is a male predominance of acute myeloid leukemia (AML) incidence, but survival data are conflicting. The objective of this study is to carry out a comprehensive analysis of sex differences in AML, and to investigate the impact of sex disparities in survival.

METHODS

The cohort included patients ≥18 years diagnosed with AML (2010-2022). Demographics, treatment patterns, treatment adverse events, and survival were analyzed. The population was described and compared by sex, and sex-based risks and associations were obtained via Cox proportional-hazards regression.

RESULTS

In total, 1020 AML patients were analyzed (57.4% males), with lower risk of death for females (aHR = 0.41, 95% CI 0.26-0.66). Among females, BMT (aHR = 0.51, 95% CI 0.27-0.97), hospitalization record (aHR = 0.65, 95%CI 0.45-0.93), and higher appointment completion rates (aHR = 0.98, 95% CI 0.98-0.98) were associated with lower risk of death. Overall, and similarly in males, higher age at diagnosis (aHR = 1.03, 95% CI 1.02-1.04) and a TP53 mutation (aHR = 2.24, 95% CI 1.69-2.97) were associated with higher risk of death.

CONCLUSION

Sex differences exist in both AML incidence and overall survival. Treatment and health care factors should be addressed by caregivers and public policies developed to reduce mortality rates and mitigate existing sex differences.

Molecular characteristics and outcomes in Hispanic and non-Hispanic patients with acute myeloid leukemia

Hispanic patients have been reported to have an increased incidence of AML and possibly inferior outcomes compared to non-Hispanics. We conducted a retrospective study of 225 AML patients (58 Hispanic and 167 non-Hispanic) at two academic medical centers in Florida. Disease characteristics, cytogenetics, mutation profiles, and clinical outcomes were assessed. Hispanic patients were younger at presentation than non-Hispanics (p = 0.0013). We found associations between single gene mutations and ethnicity, with IDH1 mutations being more common in non-Hispanics (95.2% vs. 4.8%, p = 0.0182) and WT1 mutations more common in Hispanics (62.5% vs. 37.5%, p = 0.0455). We also found an emerging trend towards adverse risk cytogenetics in Hispanic patients (p = 0.1796), as well as high risk fusions such as MLL-r (70% vs. 30%, p = 0.004). There was no difference in overall survival (OS) between Hispanic and non-Hispanics patients. When examining only newly diagnosed patients (n = 105), there was improved OS in Hispanics (median 44.7 months vs. 14 months, p = 0.026) by univariate analysis and equivalent OS by multivariate analysis (hazard ratio = 1.52 [95% CI = 0.74-3.15]). Hispanics with a driver mutation not class-defining had improved survival compared to non-Hispanics. Our study demonstrates significant genetic differences between Floridian Hispanics and non-Hispanics, but no difference in OS in patients treated at an academic medical center.

Secondary malignancies in non-Hodgkin lymphoma survivors: 40 years of follow-up assessed by treatment modality

BACKGROUND

Survivors of non-Hodgkin lymphoma (NHL) have increased secondary malignancy (SM) risk. We quantified this risk by patient and treatment factors.

METHODS

Standardized incidence ratios (SIR, observed-to-expected [O/E] ratio) were assessed in 142,637 NHL patients diagnosed from 1975 to 2016 in the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. Comparisons were made between subgroups in terms of their SIRs relative to respective endemic populations.

RESULTS

In total, 15,979 patients developed SM, more than the endemic rate (O/E 1.29; p < 0.05). Compared with white patients, relative to respective endemic populations, ethnic minorities had a higher risk of SM (white O/E 1.27, 95% CI 1.25-1.29; black O/E 1.40, 95% CI 1.31-1.48; other O/E 1.59, 95% CI 1.49-1.70). Relative to respective endemic populations, patients who received radiotherapy had similar SM rates to those who did not (O/E 1.29 each), but irradiated patients had increased breast cancer (p < 0.05). Patients who received chemotherapy had higher SM rates than those who did not (O/E 1.33 vs. 1.24, p < 0.05) including more leukemia, Kaposi sarcoma, kidney, pancreas, rectal, head and neck, and colon cancers (p < 0.05).

CONCLUSIONS

This is the largest study to examine SM risk in NHL patients with the longest follow-up. Treatment with radiotherapy did not increase overall SM risk, while chemotherapy was associated with a higher overall risk. However, certain subsites were associated with a higher risk of SM, and they varied by treatment, age group, race and time since treatment. These findings are helpful for informing screening and long-term follow-up in NHL survivors.

The impact of race, ethnicity, and obesity on CAR T-cell therapy outcomes

Cancer outcomes with chemotherapy are inferior in patients of minority racial/ethnic groups and those with obesity. Chimeric antigen receptor (CAR) T-cell therapy has transformed outcomes for relapsed/refractory hematologic malignancies, but whether its benefits extend commensurately to racial/ethnic minorities and patients with obesity is poorly understood. With a primary focus on patients with B-cell acute lymphoblastic leukemia (B-ALL), we retrospectively evaluated the impact of demographics and obesity on CAR T-cell therapy outcomes in adult and pediatric patients with hematologic malignancies treated with CAR T-cell therapy across 5 phase 1 clinical trials at the National Cancer Institute from 2012 to 2021. Among 139 B-ALL CAR T-cell infusions, 28.8% of patients were Hispanic, 3.6% were Black, and 29.5% were overweight/obese. No significant associations were found between race, ethnicity, or body mass index (BMI) and complete remission rates, neurotoxicity, or overall survival. Hispanic patients were more likely to experience severe cytokine release syndrome compared with White non-Hispanic patients even after adjusting for leukemia disease burden and age (odds ratio, 4.5; P = .001). A descriptive analysis of patients with multiple myeloma (n = 24) and non-Hodgkin lymphoma (n = 23) displayed a similar pattern to the B-ALL cohort. Our findings suggest CAR T-cell therapy may provide substantial benefit across a range of demographics characteristics, including for those populations who are at higher risk for chemotherapy resistance and relapse. However, toxicity profiles may vary. Therefore, efforts to improve access to CAR therapy for underrepresented populations and elucidate mechanisms of differential toxicity among demographic groups should be prioritized.

Are Pivotal Clinical Trials for Drugs Approved for Leukemias and Multiple Myeloma Representative of the Population at Risk?

PURPOSE

There are significant disparities in care and outcomes for patients with leukemias and multiple myeloma (MM). To evaluate the extent to which clinical trials (CTs) match the demographic and geographic diversity of populations affected by leukemias and MM.

METHODS

CTs leading to drug approval were identified from the US Food and Drug Administration databases. Demographic and geographic data were collected from ClinicalTrials.gov and primary manuscripts. Standard descriptive statistics were used to summarize the data in frequencies and proportions, including 95% CIs, by race, ethnicity, sex, and malignancy subtypes.

RESULTS

A total of 41 (67.2%) trials leading to drug approval reported data on race and 20 (48.8%) on ethnicity. These trials included 13,731 patients, of whom 11,209 (81.6%) were White. Among minorities, Asian-Pacific Islanders and Blacks had the highest representation in chronic myeloid leukemia, 147 (12.7%) and 61 (5.3%), and lowest in chronic lymphocytic leukemia, 55 (3%) and 20 (1.1%), respectively. Proportions for Blacks, Native Americans, and Hispanics were significantly low, reflecting under-representation in trials compared with the proportion in the general population. Females were also under-represented in acute myeloid leukemia (44.7% v 60.5%, P < .0001), and males in MM (55.3% v 60.2%, P < .0001) and chronic myeloid leukemia (55.2% v 62.9%, P < .0001). The geographic distribution of trials showed inadequate regional and state participation compared with mortality for all malignancies except MM.

CONCLUSION

There are significant demographic and geographic under-representation and imbalances in pivotal CTs leading to drug approvals for leukemias and MM compared with the population affected. These disparities need to be addressed to make results applicable to all relevant populations.

Association between Cholesterol Level and the Risk of Hematologic Malignancy According to Menopausal Status: A Korean Nationwide Cohort Study

Recent studies have revealed the possible association between serum cholesterol levels and hematologic malignancy (HM). However, limited information is available about how reproductive factors interact with this association. Therefore, we investigated the roles of serum cholesterol in the risk of HM according to the menopausal status. We finally identified 1,189,806 premenopausal and 1,621,604 postmenopausal women who underwent a national health screening program in 2009 using data from the Korean National Health Insurance Service database. Overall, 5449 (0.19%) developed HM. Among postmenopausal women, the inverse associations were observed between total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) levels, and the risk of overall HM. In premenopausal women, the highest quartile of HDL-C was associated with a reduced risk of HM compared with the lowest quartile of HDL-C consistent with results in postmenopausal women (adjusted hazard ratio [aHR] 0.80, 95% confidence interval [CI] [0.68–0.95]), whereas the highest quartile of triglyceride (TG) showed an increased risk of HM compared to the lowest quartile of TG, (aHR 1.22, 95% CI [1.02,1.44]) only in premenopausal women. Our finding suggests that lipid profiles are differently associated with HM risk by menopausal status.

Epidemiologic evaluation of clinical outcomes in ethnic minorities with myelodysplastic syndromes

Since race/ethnicity and socioeconomic status (SES), including economic and educational disadvantage (EED), may impact overall survival (OS) in primary myelodysplastic syndromes (MDS), we analyzed the impact of these characteristics on OS in Non-Hispanic White (NHW), Non-Hispanic Black (NHB) and Hispanic patients. In this retrospective review using the SEER US population and American Community Survey data between 2001 and 2016, factor analysis was used for 23 county-level SES indicators to identify groups of interrelated measures of EED. For the 52,739 patients identified, increased age at diagnosis, male sex, higher prognostic risk category and higher EED were all associated with reduced OS. The most prominent SES factor extracted by factor analysis was EED. NHB patients had the highest OS compared to NHW and Hispanics. For all patients, EED analysis showed lower OS for most compared to least disadvantaged, most notably in lower-risk disease and Hispanics. More NHB and Hispanics (51% and 49%) were in the most disadvantaged category compared with NHW (30%). No significant differences were noted for causes of death by race/ethnicity. In conclusion, these data indicate that in addition to standard clinical measures for analyzing OS, race/ethnicity, SES and EED are critical determinants for assessing clinical outcomes in MDS patients.

American Cancer Society nutrition and physical activity guideline for cancer survivors

The overall 5-year relative survival rate for all cancers combined is now 68%, and there are over 16.9 million survivors in the United States. Evidence from laboratory and observational studies suggests that factors such as diet, physical activity, and obesity may affect risk for recurrence and overall survival after a cancer diagnosis. The purpose of this American Cancer Society guideline is to provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and cancer-specific and overall mortality. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing American Cancer Society programs, health policy, and the media. Sources of evidence that form the basis of this guideline are systematic literature reviews, meta-analyses, pooled analyses of cohort studies, and large randomized clinical trials published since 2012. Recommendations for nutrition and physical activity during cancer treatment, informed by current practice, large cancer care organizations, and reviews of other expert bodies, are also presented. To provide additional context for the guidelines, the authors also include information on the relationship between health-related behaviors and comorbidities, long-term sequelae and patient-reported outcomes, and health disparities, with attention to enabling survivors' ability to adhere to recommendations. Approaches to meet survivors' needs are addressed as well as clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis.

The Global Burden of Leukemia and Its Attributable Factors in 204 Countries and Territories: Findings from the Global Burden of Disease 2019 Study and Projections to 2030

Background. Leukemia is a common malignancy that has four main subtypes and is a threat to human health. Understanding the epidemiological status of leukemia and its four main subtypes globally is important for allocating appropriate resources, guiding clinical practice, and furthering scientific research. Methods. Average annual percentage changes (AAPCs) were calculated to estimate the change trends of age-standardized rates (ASRs) from 1990 to 2019 in 204 countries and territories. The risk factors for leukemia death and disability-adjusted life-year (DALY) were also analyzed. In addition, the future trends in ASRs were projected through 2030. Results. The total number of incident cases, deaths, and DALYs from leukemia in 2019 was 0.64, 0.33, and 11.66 million, respectively. Decreasing trends in age-standardized incidence rate (ASIR), the age-standardized death rate (ASDR), and age-standardized DALY rate were detected on a global level while increasing trends in ASIR were detected in the high-sociodemographic index (SDI) regions. The leukemia burden was heavier in males than in females. By cause, acute myeloid leukemia (AML), chronic myeloid leukemia (CML), and chronic lymphocytic leukemia (CLL) were more likely to impose a burden on the elderly, while acute lymphoblastic leukemia (ALL) showed a greater impact in the younger population. A significant positive correlation was observed between SDI and AAPC in ASIR, while SDI was negatively correlated with AAPCs in both ASDR and age-standardized DALY rate. Smoking remained the most significant risk factor associated with leukemia-related death and DALY, especially in males. Similar deaths and DALYs were caused by smoking and high body mass index (BMI) in females. Future projections through 2030 estimated that ASIR and ASDR will continue to increase, while the DALY rate is predicted to decline. Conclusions. Patterns and trends of leukemia burden are correlated with SDI. The estimated contributions to leukemia deaths indicate that timely measures are needed to reduce smoking and obesity.

Rising Incidence of Legionnaires' Disease and Associated Epidemiologic Patterns, United States, 1992-2018

Reported Legionnaires' disease (LD) cases began increasing in the United States in 2003 after relatively stable numbers for >10 years; reasons for the rise are unclear. We compared epidemiologic patterns associated with cases reported to the Centers for Disease Control and Prevention before and during the rise. The age-standardized average incidence was 0.48 cases/100,000 population during 1992-2002 compared with 2.71 cases/100,000 in 2018. Reported LD incidence increased in nearly every demographic, but increases tended to be larger in demographic groups with higher incidence. During both periods, the largest number of cases occurred among White persons, but the highest incidence was in Black or African American persons. Incidence and increases in incidence were generally largest in the East North Central, Middle Atlantic, and New England divisions. Seasonality was more pronounced during 2003-2018, especially in the Northeast and Midwest. Rising incidence was most notably associated with increasing racial disparities, geographic focus, and seasonality.

Black patients with multiple myeloma have better survival than white patients when treated equally: a matched cohort study

We assessed differences in survival between non-Hispanic black (NHB) and non-Hispanic white (NHW) patients with multiple myeloma (MM), and the sequential effects of patient characteristics, and diagnosis and treatment-related factors on the survival disparity using data from 3319 NHB and 20,831 NHW MM patients in the SEER-Medicare (1999-2017) database. Four sets of 3319 NHWs were matched sequentially to the same set of 3319 NHBs, based on demographics (age, sex, year of diagnosis, marital status, and SEER site), socioeconomic status (SES, demographics plus SES), presentation factors (SES variables plus comorbidity), and treatment factors (presentation variables plus antimyeloma therapies). We found NHBs were less likely to receive treatment than NHWs even among patients matched for demographics, SES, and comorbidities. The absolute difference in 5-year survival between NHBs and NHWs was not significant in the demographics match (0.6%; P = 0.30) and remained non-significant after matching for SES (1.4%, P = 0.17). When matching for presentation, NHBs had significantly longer 5-year survival than NHWs (absolute difference = 3.8%, P = 0.003). Additional matching on treatment-related factors further enlarged the racial difference in 5-year survival to 4.6% (P < 0.001). Our findings reinforce the importance of equitable access to effective treatment modalities to further improve the survival of NHB patients with MM.

Loss of independence as a metric for racial disparities in lower extremity amputation for diabetes: A National Surgery Quality Improvement Program (NSQIP) analysis

INTRODUCTION

This study assessed the association between race/ethnicity and amputation with mortality and loss of independence (LOI) for diabetic gangrene.

METHODS

We analyzed the American College of Surgeons National Surgery Quality Improvement Program database from 2016 to 2019. Chi-squared tests were performed to evaluate differences in baseline characteristics and complications. Multivariable logistic regression was performed to model LOI and 30-day mortality.

RESULTS

5250 patients with diabetes underwent lower extremity amputation as treatment for gangrene. Hispanic patients were more likely to undergo below the knee amputation (BKA) (P = 0.006). Guillotine amputation (GA) was associated with age > 65 (P < 0.0001), independent functional status prior to admission (P < 0.0001), and mortality (OR 1.989, 95%CI 1.29-3.065), but was not associated with LOI. Mortality was less frequent in Black patients (OR 0.432, 95%CI 0.207-0.902), but loss of independence (LOI) was more frequent in Black patients (OR 1.373, 95%CI 1.017-1.853). Hispanic patients were less likely to experience LOI (OR 0.575, 95%CI 0.477-0.693).

CONCLUSIONS

LOI and mortality provide contrasting perspectives on outcomes following lower extremity amputation. Further assessment of risk factors may illuminate healthcare disparities.

In-hospital Mortality and Racial Disparity in Children and Adolescents With Acute Myeloid Leukemia: A Population-based Study

Survival disparities in children and adolescents with acute myeloid leukemia (AML) are documented, however, the etiology of these disparities is understudied. Few studies have evaluated factors that predict in-hospital mortality in childhood AML and racial/ethnic disparities associated with in-hospital death. Our study aimed to investigate factors associated with the risk of in-hospital death among childhood AML hospitalizations. We conducted a retrospective study of childhood AML hospitalizations using the National Inpatient Sample (NIS) from 2003 to 2017. We estimated incidences of in-hospital death among AML hospitalizations. We performed survey logistic regression models to measure the association between patient and hospital characteristics and in-hospital mortality. We identified 71,050 hospitalizations of children with AML. Compared with non-Hispanic (NH) whites, NH-black children had a higher risk of in-hospital mortality (adjusted odds ratio: 1.41, 95% confidence interval: 1.06-1.87, P<0.02). Further, NH-black patients with hematopoietic stem cell transplant experienced the highest risk of mortality (adjusted odds ratio: 5.88, 95% confidence interval: 3.13-11.06, P<0.001) as compared with NH-black children who did not receive hematopoietic stem cell transplant. Our findings highlight that NH-black children with AML continue to experience a disproportionately higher likelihood of in-hospital mortality when compared with their NH-white counterparts. Further studies are needed to delineate the etiology of these disparities.

Hematopoietic cell transplantation for sickle cell disease: updates and future directions

Excellent outcomes in hematopoietic cell transplantation (HCT) from HLA-identical siblings, improvements in conditioning regimens, novel graft-versus-host disease prophylaxis, and the availability of alternative donors have all contributed to the increased applicability and acceptability of HCT for sickle cell disease (SCD). In young children with symptomatic SCD with an available HLA-identical related donor, HCT should be carefully considered. HCT from alternative donors is typically undertaken only in patients with severe symptoms, causing or likely to cause organ damage, and in the context of clinical trials. Patients undergoing HCT for SCD require careful counseling and preparation. They require careful monitoring of unique organ toxicities and complications during HCT. Patients must be prospectively followed for a prolonged time to determine the long-term outcomes and late effects of HCT for SCD. Thus, there is a need for a universal, longitudinal clinical registry to follow patients after HCT for SCD in conjunction with individuals who do not receive HCT to compare outcomes. Antibody-based conditioning and ex-vivo umbilical cord blood expansion are likely to improve the availability and acceptability of HCT. In addition, new disease-modifying drugs and the emerging option of the autologous transplantation of gene-modified hematopoietic progenitor cells are likely to expand the available therapeutic options and make decision-making by patients, physicians, and caregivers even more complicated. Future efforts must also focus on determining the impact of socioeconomic status on access to and outcomes of HCT and the long-term impact of HCT on patients, families, and society.