Effects of Education and Income on Treatment and Outcome in Patients With Acute Myeloid Leukemia in a Tax-Supported Health Care System: A National Population-Based Cohort Study

Abstract

Purpose Previous US studies have shown that socioeconomic status (SES) affects survival in acute myeloid leukemia (AML). However, no large study has investigated the association between education or income and clinical characteristics, treatment, and outcome in AML. Methods To investigate the effects of education and income in a tax-supported health care system, we conducted a population-based study using individual-level SES and clinical data on all Danish patients with AML (2000 to 2014). We compared treatment intensity, allogeneic transplantation, and response rates by education and income level using logistic regression (odds ratios). We used Cox regression (hazard ratios [HRs]) to compare survival, adjusting for age, sex, SES, and clinical prognostic markers. Results Of 2,992 patients, 1,588 (53.1%) received intensive chemotherapy. Compared with low-education patients, highly educated patients more often received allogeneic transplantation (16.3% v 8.7%). In intensively treated patients younger than 60 years of age, increased mortality was observed in those with lower and medium education (1-year survival, 66.7%; adjusted HR, 1.47; 95% CI, 1.11 to 1.93; and 1-year survival, 67.6%; adjusted HR, 1.55; CI, 1.21 to 1.98, respectively) compared with higher education (1-year survival, 76.9%). Over the study period, 5-year survival improvements were limited to high-education patients (from 39% to 58%), increasing the survival gap between groups. In older patients, low-education patients received less intensive therapy (30% v 48%; adjusted odds ratio, 0.65; CI, 0.44 to 0.98) compared with high-education patients; however, remission rates and survival were not affected in those intensively treated. Income was not associated with therapy intensity, likelihood of complete remission, or survival (high income: adjusted HR, 1.0; medium income: adjusted HR, 0.96; 95% CI, 0.82 to 1.12; low income: adjusted HR, 1.06; CI, .88 to 1.27). Conclusion In a universal health care system, education level, but not income, affects transplantation rates and survival in younger patients with AML. Importantly, recent survival improvement has exclusively benefitted highly educated patients.

Utilization of initial chemotherapy for newly diagnosed acute myeloid leukemia in the United States

“…Prior studies have also demonstrated a lower receipt of chemotherapy with increasing age and greater burden of comorbidities [8][9][10][11]13 ( Table 3). Two of the prior studies 8,9 were performed only on Medicare patients aged 65 years or older; hence, these 2 studies do not inform factors associated with the receipt of chemotherapy in younger patients.…”

“…10 This study had suggested that future studies should explore the role of socioeconomic factors and treatment facility location on leukemia care disparity. The study from Denmark 13 highlighted that the utilization of intensive chemotherapy was lower among older patients, particularly those with lower education and lower income levels. The country has universal healthcare; hence, the study only focused on understanding the effect of education and income levels.…”

“…Prior studies have demonstrated a lower receipt of chemotherapy with increasing age of patients and increasing comorbidities. [8][9][10][11]13 Previously, we have demonstrated that the likelihood of receiving chemotherapy was higher among patients treated in academic as compared with nonacademic centers. 12 Extending on our initial observations, we have performed a study using the large National Cancer Database (NCDB) specifically to determine the use of upfront chemotherapy in AML in more recent years and to determine several factors associated with the receipt of chemotherapy.…”

Systematic patient involvement for homebased outpatient administration of complex chemotherapy in acute leukemia and lymphoma

“…A recent qualitative study found that acute leukaemia patients within an outpatient management program expressed a growing desire to understand their long‐term care plan, and they were struggling to construct a new sense of identity (Nissim et al , ). In our outpatient AML programme, we systematically schedule the interaction and counselling with the interdisciplinary staff, which seems of utmost importance to support patients' and relatives adaptation irrespective of effective treatment or failure (Jepsen et al , ) or their underlying socio‐demographic profile (Ostgard et al , ). Likewise, the integration of rehabilitation is necessary to counteract physical decline (Jarden et al , ).…”

Patient‐based prediction algorithm of relapse after allo‐HSCT for acute Leukemia and its usefulness in the decision‐making process using a machine learning approach

“…The planned DLI and targeted posttransplant therapy may be effective at preventing relapse, but this study did not include the patients who received these therapies, so we could not evaluate their effects. The addition of social environments and educational history, which are complex factors, may also be beneficial . The outcomes of allo‐HSCT may vary among transplant centers.…”