Dhakal Prajwal, Lyden Elizabeth, Joshi Utsav, Pyakuryal Avantika, Gundabolu Krishna, Zeidan Amer M, Loh Kah Poh, Fisher Alfred L, Bhatt Vijaya Raj
Department of Internal Medicine, Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA.
Department of Biostatics, University of Nebraska Medical Center, Omaha, NE.
Clin Lymphoma Myeloma Leuk. 2022 May;22(5):319-325. doi: 10.1016/j.clml.2021.10.010. Epub 2021 Oct 25.
Despite high rate of cure in acute promyelocytic leukemia (APL) in clinical trials, outcomes in real-world practice are dismal. We utilized National Cancer Database (NCDB) to explore utilization of multiagent therapy in APL and identify any disparities in treatment in real-world practices.
NCDB categorizes use of systemic chemotherapy into single agent versus multiagent therapy. Some patients received hormonal therapy, immunotherapy, and unknown therapy; details of these treatments could not be ascertained. We therefore used multiple logistic regression analysis to evaluate effects of covariates on the probability of multiagent therapy use in 6678 patients.
Compared to patients >60 years, patients aged 0 to 18 years (hazard ratio[HR] 3.2, 95% confidence interval [CI] 1.8-5.5, P< .0001), 19 to 40 years (HR 1.6, 95% CI 1.03-2.54, P= .03), and 41 to 60 years (HR 1.6, 95% CI 1.3-1.9, P< .0001) were more likely to receive multiagent therapy. Patients with Charlson comorbidity index (CCI) of 0 (HR 1.6, 95% CI 1.2-2.3, P= .001) and CCI of 1 (HR 1.4, 95% CI 1.0-1.9, P= .04) had a higher likelihood of receiving multiagent therapy than patients with CCI ≥ 3. Patients treated at academic cancer centers, compared to those treated at community cancer center (HR 0.5, 95% CI 0.3-0.7, P= .001), comprehensive community cancer center (HR 0.7, 95% CI 0.6-0.8, P< .0001), and integrated network cancer center (HR 0.8, 95% CI 0.6-0.9, P= .02) were more likely to be treated with multiagent therapy. Compared to the patients with private insurance, those with Medicaid had increased likelihood (HR 1.2, 95% CI 1.0-1.4, P= .04) whereas uninsured patients had a lower likelihood of receiving multiagent therapy (HR 0.6, 95% CI 0.5-0.8, P= .0005).
To our knowledge, this study is the first and the largest scale analysis of treatment practices in APL in real-world practices. Our findings highlight significant disparities in treatment of APL based on age, insurance, and health-system factors.
尽管急性早幼粒细胞白血病（APL）在临床试验中的治愈率很高，但实际临床实践中的治疗效果却不容乐观。我们利用国家癌症数据库（NCDB）来探讨APL多药联合治疗的应用情况，并确定实际临床实践中治疗方面的差异。
NCDB将全身化疗的使用分为单药治疗与多药联合治疗。部分患者接受了激素治疗、免疫治疗及不明治疗；这些治疗的具体细节无法确定。因此，我们使用多元逻辑回归分析来评估协变量对6678例患者接受多药联合治疗概率的影响。
与60岁以上患者相比，0至18岁患者（风险比[HR] 3.2，95%置信区间[CI] 1.8 - 5.5，P <.0001）、19至40岁患者（HR 1.6，95% CI 1.03 - 2.54，P =.03）以及41至60岁患者（HR 1.6，95% CI 1.3 - 1.9，P <.0001）接受多药联合治疗的可能性更高。Charlson合并症指数（CCI）为0（HR 1.6，95% CI 1.2 - 2.3，P =.001）和CCI为1（HR 1.4，95% CI 1.0 - 1.9，P =.04）的患者比CCI≥3的患者接受多药联合治疗的可能性更高。与在社区癌症中心接受治疗的患者相比，在学术癌症中心接受治疗的患者（HR 0.5，95% CI 0.3 - 0.7，P =.001）、综合社区癌症中心（HR 0.7，95% CI 0.6 - 0.8，P <.0001）以及整合网络癌症中心（HR 0.8，95% CI 0.6 - 0.9，P =.02）接受多药联合治疗的可能性更高。与有私人保险的患者相比，有医疗补助的患者接受多药联合治疗的可能性增加（HR 1.2，95% CI 1.0 - 1.4，P =.04），而未参保患者接受多药联合治疗的可能性较低（HR 0.6，95% CI 0.5 - 0.8，P =.0005）。
据我们所知，本研究是对实际临床实践中APL治疗情况的首次大规模分析。我们的研究结果凸显了基于年龄、保险和医疗系统因素的APL治疗存在显著差异。
