Cancer Research Program, ICES, Toronto, ON, Canada; Institute for Health Policy, Evaluation and Management and Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.
Biostatistics, University of Florida, Gainesville, FL, USA.
Lancet Haematol. 2023 Feb;10(2):e129-e141. doi: 10.1016/S2352-3026(22)00371-4.
Previous studies have identified racial and ethnic disparities in childhood acute lymphocytic leukaemia survival. We aimed to establish whether disparities persist in contemporaneous cohorts and, if present, are attributable to differences in leukaemia biology or insurance status.
Patients with newly diagnosed acute lymphocytic leukaemia in inpatient and outpatient centres in the USA, Canada, Australia, and New Zealand, aged 0-30 years, who had race or ethnicity data available, enrolled on eight completed Children's Oncology Group trials (NCT00103285, NCT00075725, NCT00408005, NCT01190930, NCT02883049, NCT02112916, NCT02828358, and NCT00557193) were included in this secondary analysis. Race and ethnicity were categorised as non-Hispanic White, Hispanic, non-Hispanic Black, non-Hispanic Asian, and non-Hispanic other. Event-free survival and overall survival were compared across race and ethnicity groups. The relative contribution of clinical and biological disease prognosticators and insurance status was examined through multivariable regression models, both among the entire cohort and among those with B-cell lineage versus T-cell lineage disease.
Between Jan 1, 2004, and Dec 31, 2019, 24 979 eligible children, adolescents, and young adults with acute lymphocytic leukaemia were enrolled, of which 21 152 had race or ethnicity data available. 11 849 (56·0%) were male and 9303 (44·0%) were female. Non-Hispanic White patients comprised the largest racial or ethnic group (13 872 [65·6%]), followed by Hispanic patients (4354 [20·6%]), non-Hispanic Black patients (1517 [7·2%]), non-Hispanic Asian (n=1071 [5·1%]), and non-Hispanic other (n=338 [1·6%]). 5-year event-free survival was 87·4% (95% CI 86·7-88·0%) among non-Hispanic White patients compared with 82·8% (81·4-84·1%; hazard ratio [HR] 1·37, 95% CI 1·26-1·49; p<0·0001) among Hispanic patients and 81·8% (79·3-84·0; HR 1·45, 1·28-1·65; p<0·0001) among non-Hispanic Black patients. Non-hispanic Asian patients had a 5-year event-free survival of 88·1% (95% CI 85·5-90·3%) and non-Hispanic other patients had a survival of 82·8% (76·4-87·6%). Inferior event-free survival among Hispanic patients was substantially attenuated by disease prognosticators and insurance status (HR decreased from 1·37 [1·26-1·49; p<0·0001] to 1·11 [1·00-1·22; p=0·045]). The increased risk among non-Hispanic Black patients was minimally attenuated (HR 1·45 [1·28-1·65; p<0·0001] to 1·32 [1·14-1·52; p<0·0001]). 5-year overall survival was 93·6% (91·5-95·1%) in non-Hispanic Asian patients, 93·3% (92·8-93·7%) in non-Hispanic White patients, 89·9% (88·7-90·9%) in Hispanic, 89·7% (87·6-91·4%) in non-Hispanic Black patients, 88·9% (83·2-92·7%) in non-Hispanic other patients. Disparities in overall survival were wider than event-free survival (eg, among non-Hispanic other patients, the HR for event-free survival was 1·43 [1·10-1·85] compared with 1·74 [1·27-2·40] for overall survival). Disparities were restricted to patients with B-cell acute lymphocytic leukaemia, no differences in event-free survival or overall survival were seen in the T-cell acute lymphocytic leukaemia group.
Substantial disparities in outcome for B-cell acute lymphocytic leukaemia persist by race and ethnicity, but are not observed in T-cell acute lymphocytic leukaemia. Future studies of relapsed patients, access to and quality of care, and other potential aspects of structural racism are warranted to inform interventions aimed at dismantling racial and ethnic disparities.
National Cancer Institute and St Baldrick's Foundation.
先前的研究已经确定了儿童急性淋巴细胞白血病生存方面存在种族和民族差异。我们旨在确定在当代队列中是否存在差异持续存在，如果存在，是否归因于白血病生物学或保险状况的差异。
在美国、加拿大、澳大利亚和新西兰的住院和门诊中心，纳入新诊断为急性淋巴细胞白血病的患者，年龄在 0-30 岁之间，具有种族或族裔数据，入组了八项已完成的儿童肿瘤组临床试验（NCT00103285、NCT00075725、NCT00408005、NCT01190930、NCT02883049、NCT02112916、NCT02828358 和 NCT00557193）。对种族和族裔进行了分类，包括非西班牙裔白人、西班牙裔、非西班牙裔黑人、非西班牙裔亚裔和非西班牙裔其他。比较了不同种族和族裔组的无事件生存和总生存情况。通过多变量回归模型，在整个队列和 B 细胞谱系与 T 细胞谱系疾病患者中，检查了临床和生物学疾病预后因素以及保险状况的相对贡献。
2004 年 1 月 1 日至 2019 年 12 月 31 日期间，纳入了 24979 名符合条件的急性淋巴细胞白血病儿童、青少年和年轻人，其中 21152 人有种族或族裔数据。11849 名（56.0%）为男性，9303 名（44.0%）为女性。非西班牙裔白人患者占最大的种族或族裔群体（65.6%），其次是西班牙裔患者（20.6%）、非西班牙裔黑人患者（7.2%）、非西班牙裔亚裔患者（n=1071[5.1%]）和非西班牙裔其他患者（n=338[1.6%]）。非西班牙裔白人患者的 5 年无事件生存率为 87.4%（95%CI 86.7-88.0%），与西班牙裔患者的 82.8%（81.4-84.1%；危险比[HR]1.37，95%CI 1.26-1.49；p<0.0001）和非西班牙裔黑人患者的 81.8%（79.3-84.0%；HR 1.45，1.28-1.65；p<0.0001）相比，非西班牙裔黑人患者的 5 年无事件生存率明显较低。非西班牙裔亚裔患者的 5 年无事件生存率为 88.1%（95%CI 85.5-90.3%），非西班牙裔其他患者的生存率为 82.8%（76.4-87.6%）。西班牙裔患者的无事件生存率明显降低，疾病预后因素和保险状况显著减弱（HR 从 1.37（1.26-1.49；p<0.0001）降至 1.11（1.00-1.22；p=0.045））。非西班牙裔黑人患者的风险增加程度略有减弱（HR 从 1.45（1.28-1.65；p<0.0001）降至 1.32（1.14-1.52；p<0.0001））。非西班牙裔亚裔患者的 5 年总生存率为 93.6%（91.5-95.1%），非西班牙裔白人患者为 93.3%（92.8-93.7%），西班牙裔患者为 89.9%（88.7-90.9%），非西班牙裔黑人患者为 89.7%（87.6-91.4%），非西班牙裔其他患者为 88.9%（83.2-92.7%）。总生存率的差异大于无事件生存率（例如，在非西班牙裔其他患者中，无事件生存率的 HR 为 1.43[1.10-1.85]，而总生存率的 HR 为 1.74[1.27-2.40]）。差异仅限于 B 细胞急性淋巴细胞白血病患者，在 T 细胞急性淋巴细胞白血病组中，无事件生存率或总生存率无差异。
B 细胞急性淋巴细胞白血病的种族和族裔差异持续存在，但在 T 细胞急性淋巴细胞白血病中未观察到。需要进一步研究复发性患者、获得和护理质量以及其他潜在的结构性种族主义方面的问题，为旨在消除种族和族裔差异的干预措施提供信息。
美国国立癌症研究所和圣裘德儿童研究医院。
