Impact of Sociodemographic Factors on Mortality in Acute Myeloid Leukemia in the United States: A Time-Trend Analysis

Background:

In the past several years, there have been major advancements in understanding the pathogenesis of acute myeloid leukemia (AML). This has led to the approval of several therapeutic regimens resulting in improved overall survival. Despite this, due to disease complexity, mortality remains high. It is not well known if these advances in therapeutics, urgent access to specialized care and improved supportive measures have reduced mortality in the last two decades. Furthermore, the influence of sociodemographic factors on the risk of mortality also remains unclear.

Methods:

We utilized the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database to access National Vital Statistics System data to determine mortality trends in patients with AML from 1999 to 2022. Deaths related to AML in adults were identified from multiple causes of death database. Cases were grouped and analyzed by age (<65y and ≥65y), race/ethnicity, gender and residency in rural or urban counties. Age-adjusted mortality rates per 100,000 persons (AAMR) were calculated and standardized to the 2000 US census data. Joinpoint regression was used to examine trends in annual percentage change (APC) and average annual percentage change (AAPC).

Results:

A total of 227,799 deaths related to AML were identified (62,804 <65y and 164,995 ≥65y) between 1999 and 2022. The AAMR increased from 3.86 in 1999 to 4.53 in 2009 (APC 4.77, p<0.001) and then decreased to 4.19 in 2022 (APC -0.25, p=0.04). For patients <65y, the AAMR declined from 1.49 in 1999 to 1.31 in 2020 (AAPC -0.54, p=0.006). For patients ≥65y, AAMR increased from 13.7 in 1999 to 16.8 in 2020 (AAPC 0.94, p<0.001). For male patients, AAMR increased from 4.94 in 1999 to 5.38 in 2022 (AAPC 0.47, p<0.001) although a decline in APC was observed from 2009-2022 (APC -0.3, p=0.04). For female patients, the AAMR did not change significantly from 1999 to 2022. For non-Hispanic whites (NHWs), the AAMR increased from 4.06 in 1999 to 4.71 in 2020 (AAPC 0.68, p<0.001). For non-Hispanic blacks (NHBs), the AAMR increased from 3.22 in 1999 to 3.66 in 2020 (AAPC 0.52, p<0.001). For Asian or Pacific Islanders, the AAMR increased from 2.3 in 2000 to 3.01 in 2020 (AAPC 0.87, p=0.02). For American Indian or Alaskan natives, the AAMR decreased from 2.95 in 2000 to 1.62 in 2020 (APC -0.8, p=0.4). The overall mortality from AML was highest in NHWs (AAMR 5.52) followed by NHBs (AAMR 3.02) and was lowest for American Indian or Alaskan natives (AAMR 1.59). From 1999 to 2020, as per the 2013 NCHS Urban-Rural Scheme for Counties, AAMR for residents of urban counties increased from 4.0 in 1999 to 4.3 in 2009 (APC 0.92, p<0.001) and then decreased to 4.15 in 2020 (APC -0.51, p=0.03). For residents of rural areas, the AAMR increased from 3.85 in 1999 to 4.5 in 2020 (AAPC 0.7, p=0.003).

Conclusion:

In recent years, although mortality from AML has decreased for the overall population, there exist differences in outcomes based on sociodemographic factors. We find that the mortality among AML patients <65y, of American Indian or Alaskan native race as well as those living in urban areas has decreased over time. Unfortunately, the mortality for older AML patients, NHWs, NHBs, Asian or Pacific Islanders as well as those living in rural areas has gradually increased over time. Furthermore, overall mortality from AML was highest in NHWs and lowest in American Indian or Alaskan native race. Our findings highlight sociodemographic determinants of mortality in AML and emphasize the need for additional resources to address these barriers.