Background: Despite highly successful treatment approach,Acute lymphoblastic leukemia (ALL) still leads to significant number of deaths every year. It is a more common disease in children but 80% of ALL-associated deaths occurs in adults. In the US pediatric population, low socioeconomic status (SES) is associated with increased mortality. This association has not been well studied in adults. Most adult studies have focused on SES association with likelihood of treatment but not survival outcomes. One large study reported an association of lower overall survival with minority race for patients diagnosed with ALL between 1980 and 2017 but most of the patients were children and the analysis spanned eras with different types of treatments (Sasaki, K. et al, Am J Hematol, 2021). Here, we report on the analysis of a large dataset to measure the association of survival outcomes with sociodemographic characteristics of adult patients diagnosed with ALL in the United States (U.S) in the modern era.

Methods: The Surveillance, Epidemiology, and End Results SEER*Stat software, version 8.4.4, from the National Cancer Institute was used to identify cases of ALL patients in the United States (US). The analytic sample was restricted to patients aged 20 or older diagnosed with ALL between 2000 and 2021, extracted from the SEER Research Plus Data, 17 Registries, Nov 2023 Sub (2000-2021), with linkage to county attributes (1969-2022). The primary outcome of interest is 5-year survival. Sociodemographic characteristics evaluated include race/ethnicity, age, sex, marital status, zip-code level income, urbanicity, and COC-accreditation status. We use multivariable Cox proportional hazard regression to evaluate the association between survival outcomes and sociodemographic factors. Statistical analyses were conducted in SAS 9.4® and statistical significance was set to p<0.05.

Results: The sample size was 13,094 patients with 32% aged 20-39, 32% 40-59 and 36% 60 and above. The racial/ethnic breakdown of the sample included 52% non-Hispanic White (NHW), 32% Hispanic, 7% non-Hispanic Black (NHB), 8% Asian and 1% “other” patients. Marital status included: married (52%), single (29%), divorced/separated (8%), widowed (7%) and unknown(4%). 2094 (16%) patients lived in areas with median income of >$100,000 compared with 10370 (79%) patients in areas with median income of $50,000-$100,000 and 624 (5%) patients in areas with median income of < $50,000. 63% of patients lived in large urban areas, 21% in medium urban area, 7% in small urban area and 9% in rural area. Most patients (86%) were treated with chemotherapy. Starting in 2018, COC-accreditation was reported for treatment centers and for the 2948 patients diagnosed in 2018 or later, 2566 (87%) of them were treated in accredited centers.

The results of the multivariable analysis of the primary outcome indicate that, compared to NHW, NHB and Hispanics had increased risk of dying (HR 1.18, CI 1.08-1.29, p=<0.001 and HR 1.17, CI 1.11-1.24, p<0.001, respectively). Compared to married individuals, there was lower survival among single (HR 1.08, CI 1.02-1.15, p= 0.001), divorced/separated (HR 1.17, CI 1.08-1.27), p< 0.001), and widowed individuals (HR 1.43, CI 1,32-1.56, p<0.001). While urbanicity was not associated with survival, it was lower for those in area with median income <$50,000 (HR 1.22, CI 1.07-1.40, p=0.003) or $50,000-100,000 (HR 1.14, CI 1.07-1.22, p<0.001) compared to patients living in areas with median income >$100,000. As has been previously reported, older age is associated with lower survival compared to patients aged 20-39. Lastly, for the 2566 patients treated after 2018, treatment at a non-COC-accredited center was associated with shorter survival (HR 1.25, CI 1.06-1.47, p=0.008).Conclusions: This study represents one of the largest analyses of adult patients diagnosed with ALL in the new century. It shows an association of survival outcomes with sociodemographic characteristics including proxy variable of SES. Despite the limitations of the publicly available dataset lacking in patient-specific information, these associations contribute important insight into the potential importance of social support and community resources in the successful management of adult patients with ALL and warrant prospective studies into the impact of interventions aimed at improving equitable access to care and mitigating the impact of social isolation.

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2025
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