贫困与靶向免疫治疗：高危神经母细胞瘤儿童肿瘤组临床试验中的生存情况。
Poverty and Targeted Immunotherapy: Survival in Children's Oncology Group Clinical Trials for High-Risk Neuroblastoma.
机构信息
Department of Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
出版信息
J Natl Cancer Inst. 2021 Mar 1;113(3):282-291. doi: 10.1093/jnci/djaa107.
BACKGROUND
Whether social determinants of health are associated with survival in the context of pediatric oncology-targeted immunotherapy trials is not known. We examined the association between poverty and event-free survival (EFS) and overall survival (OS) for children with high-risk neuroblastoma treated in targeted immunotherapy trials.
METHODS
We conducted a retrospective cohort study of 371 children with high-risk neuroblastoma treated with GD2-targeted immunotherapy in the Children's Oncology Group trial ANBL0032 or ANBL0931 at a Pediatric Health Information System center from 2005 to 2014. Neighborhood poverty exposure was characterized a priori as living in a zip code with a median household income within the lowest quartile for the cohort. Household poverty exposure was characterized a priori as sole coverage by public insurance. Post hoc analyses examined the joint effect of neighborhood and household poverty using a common reference. All statistical tests were 2-sided.
RESULTS
In multivariable Cox regressions adjusted for disease and treatment factors, household poverty-exposed children experienced statistically significantly inferior EFS (hazard ratio [HR] = 1.90, 95% confidence interval [CI] = 1.28 to 2.82, P = .001) and OS (HR = 2.79, 95% CI = 1.63 to 4.79, P < .001) compared with unexposed children. Neighborhood poverty was not independently associated with EFS or OS. In post hoc analyses exploring the joint effect of neighborhood and household poverty, children with dual-poverty exposure (neighborhood poverty and household poverty) experienced statistically significantly inferior EFS (HR = 2.21, 95% CI = 1.48 to 3.30, P < .001) and OS (HR = 3.70, 95% CI = 2.08 to 6.59, P < .001) compared with the unexposed group.
CONCLUSIONS
Poverty is independently associated with increased risk of relapse and death among neuroblastoma patients treated with targeted immunotherapy. Incorporation of social and environmental factors in future trials as health-care delivery intervention targets may increase the benefit of targeted therapies.
背景
社会决定因素是否与儿科肿瘤靶向免疫治疗试验中的生存有关尚不清楚。我们研究了贫困与高危神经母细胞瘤患儿无事件生存（EFS）和总生存（OS）之间的关系，这些患儿在靶向免疫治疗试验中接受治疗。
方法
我们对 2005 年至 2014 年期间在儿科健康信息系统中心接受 GD2 靶向免疫治疗的 371 例高危神经母细胞瘤患儿进行了回顾性队列研究。该研究中的患儿均参与了儿童肿瘤学组的 ANBL0032 或 ANBL0931 试验。预先确定的邻里贫困暴露特征是居住在队列中家庭收入中位数处于最低四分位的邮政编码内。预先确定的家庭贫困暴露特征是仅由公共保险覆盖。事后分析使用共同参照来检验邻里和家庭贫困的联合效应。所有统计检验均为双侧检验。
结果
在多变量 Cox 回归分析中，根据疾病和治疗因素进行调整后，家庭贫困暴露的患儿 EFS（危险比[HR] = 1.90，95%置信区间[CI] = 1.28 至 2.82，P =.001）和 OS（HR = 2.79，95% CI = 1.63 至 4.79，P <.001）显著低于未暴露的患儿。邻里贫困与 EFS 或 OS 无独立相关性。在探索邻里和家庭贫困的联合效应的事后分析中，同时存在邻里贫困和家庭贫困的患儿 EFS（HR = 2.21，95% CI = 1.48 至 3.30，P <.001）和 OS（HR = 3.70，95% CI = 2.08 至 6.59，P <.001）显著低于未暴露的患儿。
结论
贫困与接受靶向免疫治疗的神经母细胞瘤患者复发和死亡风险增加独立相关。在未来的试验中，将社会和环境因素纳入医疗保健提供干预目标，可能会增加靶向治疗的获益。
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