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Structural racism is a mediator of disparities in acute myeloid leukemia outcomes.

ABSTRACT: Non-Hispanic Black (NHB) and Hispanic patients with acute myeloid leukemia (AML) have higher mortality rates than non-Hispanic White (NHW) patients despite more favorable genetics and younger age. A discrete survival analysis was performed on 822 adult patients with AML from 6 urban cancer centers and revealed inferior survival among NHB (hazard ratio [HR] = 1.59; 95% confidence interval [CI]: 1.15, 2.22) and Hispanic (HR = 1.25; 95% CI: 0.88, 1.79) patients compared with NHW patients. A multilevel analysis of disparities was then conducted to investigate the contribution of neighborhood measures of structural racism on racial/ethnic differences in survival. Census tract disadvantage and affluence scores were individually calculated. Mediation analysis of hazard of leukemia death between groups was examined across 6 composite variables: structural racism (census tract disadvantage, affluence, and segregation), tumor biology (European Leukemia Network risk and secondary leukemia), health care access (insurance and clinical trial enrollment), comorbidities, treatment patterns (induction intensity and transplant utilization), and intensive care unit (ICU) admission during induction chemotherapy. Strikingly, census tract measures accounted for nearly all of the NHB-NHW and Hispanic-NHW disparity in leukemia death. Treatment patterns, including induction intensity and allogeneic transplant, and treatment complications, as assessed by ICU admission during induction chemotherapy, were additional mediators of survival disparities in AML. This is the first study to formally test mediators for observed disparities in AML survival and highlights the need to investigate the mechanisms by which structural racism interacts with known prognostic and treatment factors to influence leukemia outcomes.

SUBMITTER: Abraham IE

PROVIDER: S-EPMC9710198 | biostudies-literature | 2022 Apr

REPOSITORIES: biostudies-literature

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Structural racism is a mediator of disparities in acute myeloid leukemia outcomes.

Abraham Ivy Elizabeth IE Rauscher Garth H GH Patel Anand Ashwin AA Pearse William B WB Rajakumar Priya P Burkart Madelyn M Aleem Ahmed A Dave Ami A Bharadwaj Sushma S Paydary Koosha K Acevedo-Mendez Maria M Goparaju Krishna K Gomez Richard R Carlson Kylie K Tsai Stephanie B SB Quigley John G JG Galvin John P JP Zia Maryam M Larson Melissa L ML Berg Stephanie S Stock Wendy W Altman Jessica K JK Khan Irum I

Blood 20220401 14

Non-Hispanic Black (NHB) and Hispanic patients with acute myeloid leukemia (AML) have higher mortality rates than non-Hispanic White (NHW) patients despite more favorable genetics and younger age. A discrete survival analysis was performed on 822 adult patients with AML from 6 urban cancer centers and revealed inferior survival among NHB (hazard ratio [HR] = 1.59; 95% confidence interval [CI]: 1.15, 2.22) and Hispanic (HR = 1.25; 95% CI: 0.88, 1.79) patients compared with NHW patients. A multile ...[more]

PMID: 35061876

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Project description:BackgroundAge is a strong prognostic factor in acute lymphocytic leukemia (ALL), with children doing better than adults with the same disease. One hypothesis for this age-based disparity is differences in treatment regimens. Optimizing care for adolescents and young adults (AYA) with ALL has not been well defined and disparities in care exist. We conducted a retrospective study of all veterans with ALL diagnosed between the ages of 18 and 45 since the year 2000 to evaluate disparities among prognostication methods, treatment regimens, and accrual to clinical trials with regard to age and race/ethnicity and how these factors influence overall survival.MethodsElectronic medical record data from the VA Informatics and Computing Infrastructure (VINCI) were used to identify 6,724 patients with an ICD-9 or 10 code for ALL. All patients were chart checked to confirm an ALL diagnosis between the ages of 18 and 45 and excluded if they were diagnosed before 2000, had childhood ALL, or if induction protocol was not recorded. A total of 252 patients were included in the final analysis. Multivariate analysis was performed with controls for age, ALL subtype (B, T, mixed phenotype), Ph status, cytogenetic risk (based on modified Medical Research Council-Eastern Cooperative Oncology Group (MRC-ECOG) study), obesity (body mass index (BMI) > 30), and race.ResultsPatients treated with pediatric regimens, including pediatric-inspired regimens, have statistically significant (P = 0.009) survival gains, with a hazard ratio (HR) of 0.52 after controlling for age, obesity, ALL subtype, cytogenetic risk and race. White patients had significantly improved OS compared to people of color (HR 0.57, P = 0.02) after controlling for the aforementioned covariates. Black patients were far less likely (23%) to receive a transplant than non-Black patients (46%). Only 7% of patients were treated on a clinical trial.ConclusionsThese data demonstrate that treatment with a pediatric regimen significantly improves overall survival in patients up to the age of 45 and suggests ongoing shortcomings in treatment for young adults with ALL, especially 30 to 45 years old, including persistently high use of adult induction regimens, low rates of referral to clinical trials, and significant racial disparities in bone marrow transplants for Black patients.

Project description:ImportanceUnderstanding how structural racism is associated with adolescent mental health is critical to advance health equity.ObjectiveTo assess associations between neighborhood privilege, measured by the Index of Concentration at the Extremes (ICE) and adolescent depressive symptoms, suicidality, and related racial and ethnic disparities.Design, setting, and participantsThis was a retrospective cohort study using electronic health records of adolescents aged 12 to 16 years who attended well-teen visits between 2017 and 2021. Kaiser Permanente Northern California is an integrated health care delivery system serving 4.6 million members. The cohort included 34 252 individuals born singleton at an affiliated facility from January 1, 2005, to December 31, 2009, and who had completed at least 1 mental health screener during a well-teen visit by November 23, 2021.ExposuresAmerican Community Survey 2016 to 2021 5-year estimates were used to calculate ICE scores for adolescents' residential census tract at ages 10 to 11. Three ICE measures were used as proxies of structural racism: racial privilege (ICE-race and ethnicity; hereinafter ICE-race), economic privilege (ICE-income), and combined economic and racial privilege (ICE-income plus race and ethnicity; herinafter ICE-income plus race). ICE scores were categorized into quintiles based on California statewide distributions.Main outcomes and measuresDepressive symptoms and suicidality were assessed through self-report screeners during well-teen visits. Depressive symptoms were considered to be present if patients had a score on the Patient Health Questionnaire-2 of 3 or higher (the tool uses a Likert scale to determine the frequency [0 = not at all; 3 = nearly every day] that they had depressed mood and lack of pleasure in usual activities in the past 2 weeks; responses were summed and dichotomized).ResultsAnalyses included 34 252 adolescents (12-16 years of age; mean [SD] age, 13.7 [0.8] years; 17 557 [51.3%] male, 7284 [21.3%] Asian or Pacific Islander, 2587 [7.6%] Black], 9061 [26.5%] Hispanic, 75 [0.2%] American Indian or Indigenous, 12 176 [35.5%] White, and 3069 [9%] other or unknown). Risks of depressive symptoms and suicidality generally increased with each level of declining neighborhood privilege. Adjusted risk ratios comparing adolescents from neighborhoods with the least to most racial and economic privilege were 1.37 (95% CI, 1.20-1.55) for depressive symptoms and 1.59 (95% CI, 1.23-2.05) for suicidality. Racial disparities between Black and White youth and Hispanic and White youth decreased after adjusting for each ICE measure, and became nonsignificant in models adjusting for ICE-race and ICE-income plus race.Conclusions and relevanceIn this cohort study, lower neighborhood privilege was associated with greater risks of adolescent depressive symptoms and suicidality. Furthermore, adjusting for neighborhood privilege reduced mental health disparities affecting Black and Hispanic adolescents. These findings suggest that efforts to promote equity in adolescent mental health should extend beyond the clinical setting and consider the inequitable neighborhood contexts that are shaped by structural racism.

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Structural racism is a mediator of disparities in acute myeloid leukemia outcomes.

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Structural racism is a mediator of disparities in acute myeloid leukemia outcomes.

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