Disparities in Allogeneic Hematopoietic Stem Cell Transplantation Among Acute Myeloid Leukemia Patients

Acute myeloid leukemia (AML) is the most prevalent form of leukemia. Allogeneic hematopoietic cell transplantation (Allo-HCT) is the most effective treatment for most AML subtypes and remains the only curative option for many patients. However, it is recognized that many eligible patients who could benefit from Allo-HCT do not receive this treatment, particularly African American patients. With recent advancements in donor availability, we aimed to examine whether demographic, socioeconomic status and healthcare access disparities in first-course Allo-HCT utilization have decreased over time. Data on patients diagnosed with AML between 2004 and 2019 were obtained from the National Cancer Database (N = 85,787). Adjusted linear regression models were utilized to calculate annual absolute changes (AACs) and corresponding 95% confidence intervals (CIs) across levels of previously identified significant variables to quantify trends in Allo-HCT disparities over time. Among the 85,787 patients diagnosed with AML from 2004 to 2019, non-Hispanic Black patients, those with Medicare, individuals residing in areas with lower ZIP-code-level education and income, and patients reported from community or integrated network cancer programs continuously exhibited the lowest first-course Allo-HCT rates throughout the study period. When quantifying the trends, non-Hispanic Black patients (AAC = -0.18%; 95% CI: -0.33%, -0.03%), those with Medicaid (AAC = -0.53%; 95% CI: -0.72%, -0.35%), Medicare (AAC = -0.94%; 95% CI: -1.03%, -0.86%), and those reported from community (AAC = -0.40%; 95% CI: -0.49%, -0.31%) and integrated network cancer programs (AAC = -0.06%; 95% CI: -0.17%, 0.06%) had lower AACs for first-course Allo-HCT compared to non-Hispanic White patients, those with private insurance, and those reported from academic/research programs, respectively. Patients in the highest ZIP-code-level education (AAC = 0.20%; 95% CI: 0.07%, 0.32%) and income (AAC = 0.23%; 95% CI: 0.11%, 0.35%) areas had significantly higher first-course Allo-HCT AACs compared to those residing in areas with lower education and income levels, respectively. Despite increased donor availability, subgroups that initially exhibited lower Allo-HCT rates-including racial/ethnic minorities, patients insured through Medicaid or Medicare, patients residing in lower education and income areas, and those reported from community or integrated network cancer programs-continue to demonstrate persistently lower utilization and slower growth in Allo-HCT over time, suggesting worsening of the disparities. Further research is warranted to explore factors contributing to persistent disparities in Allo-HCT utilization among underserved populations.