Impact of Socioeconomic, Demographic and Health System Factors on Therapy in Acute Myeloid Leukemia

Introduction

Acute myeloid leukemia (AML) is the most common acute leukemia in adults. Once diagnosed, AML is usually treated aggressively with the goal of improving survival. In this study, we aim to evaluate the factors affecting delivery of treatment in patients with AML.

Methods

This is a retrospective study of patients diagnosed with AML from 2003 to 2013 from the National Cancer Database (NCDB). NCDB consists of demographic variables and survival outcomes of approximately 70% of all new cancer diagnoses in the United States and Puerto Rico. Univariate logistic regression was performed to calculate crude odds ratio for different variables.

Results
A total of 98,293 patients were diagnosed with AML from 2003-2013, of which 24% (23,328) did not receive any systemic therapy (ST). On univariate analysis, the odds of receiving treatment were lower among females (Odds Ratio [OR] =0.97; 0.94-0.99), elderly (OR =0.15; 0.15-0.16), and Medicare patients (OR =0.23; 0.22- 0.23). Patients with one or more comorbidities had lower odds of receiving treatment compared to patients without any comorbidities (OR for 1 comorbidity =0.65; 0.63- 0.67, and OR for ≥ 2 comorbidities =0.42; 0.40-0.44). The odds of receiving ST were lower in community hospitals as compared to academic centers (OR= 0.34; 0.32-0.35). African Americans had higher odds of receiving ST compared to Whites (OR= 1.20; 1.13- 1.26). The patients belonging to households with higher income (>$49K) had higher odds of receiving ST (OR=1.14; 1.08-1.20). The histologic subtype associated with highest odds of receiving treatment was acute promyelocytic leukemia (OR=2.43; 2.27- 2.59). Compared to the reference period 2003-2006, patients diagnosed with AML during the later time period had higher odds for receiving therapy: 2007-2010 (OR =1.11; 1.08- 1.15), and 2011-2013 (OR =1.27; 1.22- 1.31) respectively (Table 1).

Conclusions

Although the number of people receiving therapy for AML has increased over time, factors like older age, comorbidities, lower household income, having Medicare, and being diagnosed at a community hospital were associated with lesser odds of receiving ST. More studies are needed to assess the impact of these factors on patient survival.

Table1: Systemic therapy in AML

Variable		Systemic Therapy         (% of total) n = 74965	No Systemic Therapy              (% of total) n = 23328	Odds ratio   (95% CI)
Gender	Male	41	13	1.00
	Female	35	11	0.97 (0.94, 0.99)
Age	≤ 70 y	54	6	1.00
	> 70 y	23	17	0.15 (0.15, 0.16)
Race	White	59	20	1.00
	Black	7	2	1.20 (1.13, 1.26)
	Others	10	2	1.53 (1.45, 1.61)
Year of diagnosis	2003-2006	24	8	1.00
	2007-2010	27	9	1.11(1.08,1.15)
	2011-2013	25	7	1.27 (1.22, 1.31)
Insurance	Private	32	4	1.00
	Medicaid	7	1	1.16 (1.07, 1.26)
	Medicare	29	17	0.23 (0.22, 0.23)
	No Insurance	3	1	0.61 (0.55, 0.66)
	Others	5	1	0.61 (0.57, 0.66)
Household income	< $28K	7	2	1.00
	$28K -$32,999	10	3	1.04 (0.98, 1.11)
	$33K - $38,999	14	5	1.01 (0.95, 1.08)
	$39K - $48,999	18	6	1.05 (0.99, 1.11)
	$49K +	27	8	1.14 (1.08, 1.20)
Comorbidity	None	58	15	1.00
	Only 1 comorbid condition	14	5	0.65 (0.63, 0.67)
	Two or more comorbid conditions	5	3	0.42 (0.40, 0.44)
Histology	Acute Myeloid Leukemia (AML)	42	16	1.00
	Acute Promyelocytic Leukemia (APL)	8	1	2.43 (2.27, 2.59)
	Acute Myelomonocytic Leukemia (AMyL)	6	2	1.25 (1.18, 1.32)
	Acute Myeloid Leukemia with Multilineage Dysplasia (AMLMD)	5	2	1.11 (1.05, 1.18)
	Acute Myeloid Leukemia with Maturation (AMLM)	4	1	1.56 (1.44, 1.68)
	Acute Myeloid Leukemia without Maturation (AMLWM)	3	1	2.02 (1.85, 2.21)
	Acute Myeloid Leukemia, Minimal Differentation	2	1	0.98 (0.91, 1.06)
	Other Specified Types (OST)	2	1	1.23 (1.11, 1.36)
	Erythroleukemia	2	1	1.07 (0.97, 1.18)
Facility Type (n= 83431)	Academic	50	8	1.00
	Community	29	13	0.34 (0.32, 0.35)

 AML: Acute myeloid leukemia