Poverty and relapse risk in children with acute lymphoblastic leukemia: a Children’s Oncology Group study AALL03N1 report

• Published in: Blood 2023-07, Vol.142 (3), p.221-229
• Main Authors: Wadhwa, Aman, Chen, Yanjun, Hageman, Lindsey, Hoppmann, Anna, Angiolillo, Anne, Dickens, David S., Neglia, Joseph P., Ravindranath, Yaddanapudi, Ritchey, A. Kim, Termuhlen, Amanda, Wong, F. Lennie, Landier, Wendy, Bhatia, Smita
• Format: Article
• Language: English
• Subjects: Child; Humans; Incidence; Mercaptopurine; Poverty; Precursor Cell Lymphoblastic Leukemia-Lymphoma - drug therapy; Precursor Cell Lymphoblastic Leukemia-Lymphoma - epidemiology; Recurrence
• ISSN: 0006-4971; 1528-0020; 1528-0020
• DOI: 10.1182/blood.2023019631

•Children living in extreme poverty during maintenance therapy for childhood ALL experience a 1.9-fold greater hazard of relapse.•Lower proportion of children with ALL living in extreme poverty achieve critical adherence (95%) to oral mercaptopurine. [Display omitted] The association between individual-level poverty and relapse in children receiving maintenance treatment for acute lymphoblastic leukemia (ALL) remains unclear. In a secondary analysis of COG-AALL03N1, we used data from US Census Bureau to categorize patients living below year-specific federal poverty thresholds, calculated using self-reported annual household income and size of household. Participants with federal poverty thresholds above 120% of their yearly household income were categorized as living in extreme poverty. Hazard of relapse was estimated using multivariable proportional subdistributional hazards regression for patients living in extreme poverty while receiving ALL maintenance therapy after adjusting for relevant predictors. Among 592 patients in this analysis, 12.3% of the patients were living in extreme poverty. After a median follow-up of 7.9 years, the cumulative incidence of relapse at 3 years from study enrollment among those living in extreme poverty was significantly higher (14.3%) than those not living in extreme poverty (7.6%). Multivariable analysis demonstrated that children living in extreme poverty had a 1.95-fold greater hazard of relapse than those not living in extreme poverty; this association was mitigated after the inclusion of race/ethnicity in the model, likely because of collinearity between race/ethnicity and poverty. A greater proportion of children living in extreme poverty were nonadherent to mercaptopurine (57.1% vs 40.9%); however, poor adherence did not completely explain the association between poverty and relapse risk. Future studies need to understand the mechanisms underlying the association between extreme poverty and relapse risk. This trial was registered at www.clinicaltrials.gov as #NCT00268528. In this Plenary Paper, Wadhwa et al report on a secondary analysis of the Children's Oncology Group AALL03N1 study, correlating outcomes of acute lymphoblastic leukemia with Census Bureau data detailing household income. Among 592 patients, those with incomes below 120% of federal poverty thresholds (termed extreme poverty) comprised 12%. Those living in extreme poverty have a higher rate of relapse, only partially mitigated by a higher rate of no