Neighborhood Socioeconomic Status and Overall Survival among Children with Acute Lymphoblastic Leukemia

A disadvantaged neighborhood, as represented by area-level socioeconomic status (SES) has been associated with adverse outcomes among children with acute lymphoblastic leukemia (ALL) in the US, but the duration of impact after ALL diagnosis is not well understood. This retrospective cohort study utilized the National Cancer Database (NCDB) to examine the impact of area-level SES on overall survival among children with ALL. Median income and education quartiles based on residential zip code were used to create a composite area-level SES variable. Individual-level variables included age, sex, race, year of diagnosis, primary payer, distance to care, rurality, time to treatment, and comorbidity index. Cox proportional hazard models were created overall and conditional on surviving two and five years from diagnosis. This cohort of 17,044 children with ALL was comprised of 57% males, and 61% non-Hispanic White, 24% Hispanic, 8% non-Hispanic Black, 5% Asian patients and 2% other race/ethnicities. Twelve percent (1,971) resided in the lowest SES neighborhoods, while 18% resided in the highest SES neighborhoods. Compared to those in the highest SES neighborhoods, children in the lowest SES neighborhoods had a 55% increased hazard of all-cause mortality (95%CI=1.29-1.88, P0.001). The increased hazard of mortality among those from the lowest SES neighborhoods persisted among those who survived 2 years (HR=1.70, 95%CI=1.28-2.26; P=0.001) and 5 years (HR=1.87, 95%CI=1.17-3.00; P=0.032) after ALL diagnosis. These findings suggest the need for long-term strategies to support at risk patients beyond completion of frontline therapy.