Since Nobel Prize laureate and past ASH president E. Donnall Thomas pioneered the first bone marrow transplant in 1957, allogeneic hematopoietic stem cell transplantation (allo-HSCT) has become the standard consolidation treatment for adult patients with acute myeloid leukemia (AML), particularly those with intermediate- or high-risk disease. Despite tremendous progress in chemotherapy, targeted therapies, immunotherapies, and minimal residual disease-tailored treatment, allo-HSCT remains unmatched in its ability to achieve long-term remission thanks to the "graft-versus-leukemia" effect. However, while the use of allo-HSCT for AML is increasing in the U.S., racial, ethnic, and socioeconomic disparities continue to limit access for many patients who would otherwise benefit from the treatment.
A prospective observational study, presented by Natalie Wuliji, DO, at yesterday’s Plenary Scientific Session, sheds light on the factors impacting access to allo-HSCT. Led by Mohamed Sorror, MD, MSc, the study enrolled patients from 2013 to 2017 to better understand how various barriers influence transplant outcomes — and now has more than eight years of systemically collected follow-up data. According to Alison W. Loren, MD, MSCE, director of blood and marrow transplantation at the University of Pennsylvania and plenary session introducer, the study "sets a standard for equitable cancer care, highlights critical questions that must be addressed, and emphasizes the need for academic medicine to actively engage with communities where they live."
Dr. Sorror explained how the project began: “The historical hematopoietic cell transplant-specific comorbidity index was based on data from patients who had already received a transplant, but it lacked information on those who were not offered the procedure due to potential physical and/or social barriers. This gap led us to develop a prospective study that would collect comprehensive data at specialized centers, starting from the point of AML diagnosis. By including both group of patients — those who received the transplant and those who did not — we created a unique opportunity to understand barriers to allo-HSCT.”
Conducted across 13 academic medical centers and involving 695 adult patients with AML, the study examined a range of socioeconomic factors — such as household income, educational attainment, and reliance on government assistance programs like the Supplemental Nutrition Assistance Program (food stamps) and Supplemental Security Income benefits (disability support) — and their influence on the receipt of allo-HSCT and survival outcome.
After adjusting for age, comorbidity burden, cytogenetic risk, and geriatric health, the study revealed striking patterns about socioeconomic factors and their influence on access to allo-HSCT. For example, every 10% increase in the proportion of residents in a neighborhood without a high school diploma was associated with a 24% increase in mortality without allo-HSCT and a 32% decrease in the likelihood of receiving a transplant. Similarly, for each 10% increase in the percentage of households relying on Supplemental Security Income benefits, mortality without allo-HSCT increased by 40%, while the likelihood of receiving a transplant decreased by 22%. A similar pattern was seen for households relying on Supplemental Nutrition Assistance Program benefits, where mortality increased by 18% and transplant access decreased by 9%. A modest increase in the likelihood of patients receiving a transplant was associated with higher median income, though the effect was less pronounced than that of education and government benefits, underscoring the complex role of socioeconomic status (SES) in health care access.
While SES influenced whether patients received a transplant, the study found that post-transplant survival rates were less tied to SES. According to the study authors, the main challenge is not how well patients from lower socioeconomic backgrounds fare after transplant, but whether health care providers can lower the barriers for them to access it and support them medically until a transplant can happen.
The study calls on the medical community to acknowledge the critical role of socioeconomic factors in shaping treatment access and to develop strategies to address these barriers. “Next, we are focusing on patients from lower socioeconomic backgrounds and exploring approaches from fields like solid tumors and organ transplants, which have not yet been applied to bone marrow transplant,” said Dr. Sorror. He highlighted initiatives such as hiring transplant navigators; providing funds for transportation, housing, and food; and creating infographics and videos by patients from similar backgrounds to encourage clinical trial participation.
“This study emphasizes the need to address inequities in one of the most resource-intensive areas of cancer care” said Dr. Wuliji. “We must advocate for equitable access to lifesaving therapies for all patients, regardless of their zip code.”
