McKinnell Zoe, Tuerff Daniel, Hammudi Mustafa, Hamilton Colleen, Antonio Martha, Subrahmanyam Ramesh, Ascensao Joao, Jain Maneesh Rajiv
Division of Hematology-Oncology, George Washington University Hospital, Washington, DC, USA.
Department of Hematology and Oncology, Washington DC VA Medical Center, Washington, DC, USA.
J Hematol. 2024 Aug;13(4):150-157. doi: 10.14740/jh1282. Epub 2024 Aug 15.
Age 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.
Electronic 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.
Patients 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.
These 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.
年龄是急性淋巴细胞白血病（ALL）的一个重要预后因素，患有相同疾病的儿童比成人预后更好。基于年龄的这种差异的一种假设是治疗方案的不同。优化对青少年和青年成人（AYA）ALL患者的护理尚未明确界定，且护理方面存在差异。我们对2000年以来所有年龄在18至45岁之间被诊断为ALL的退伍军人进行了一项回顾性研究，以评估在预后方法、治疗方案以及参加临床试验方面，年龄和种族/民族之间的差异，以及这些因素如何影响总生存期。
使用来自退伍军人事务部信息学和计算基础设施（VINCI）的电子病历数据来识别6724例患有ALL的ICD - 9或10编码患者。对所有患者进行病历检查，以确认在18至45岁之间诊断为ALL，若患者在2000年之前被诊断、患有儿童ALL或诱导方案未记录，则将其排除。最终分析纳入了252例患者。进行多变量分析时，控制了年龄、ALL亚型（B、T、混合表型）、Ph状态、细胞遗传学风险（基于改良的医学研究理事会 - 东部肿瘤协作组（MRC - ECOG）研究）、肥胖（体重指数（BMI）> 30）和种族。
接受儿科方案治疗的患者，包括受儿科启发的方案，在控制年龄、肥胖、ALL亚型、细胞遗传学风险和种族后，有统计学显著（P = 0.009）的生存获益，风险比（HR）为0.52。在控制上述协变量后，白人患者的总生存期相比有色人种有显著改善（HR 0.57，P = 0.02）。黑人患者接受移植的可能性远低于非黑人患者（23% 对比46%）。只有7%的患者参加了临床试验。
这些数据表明，采用儿科方案治疗可显著提高45岁及以下患者的总生存期，并提示对ALL青年成人患者，尤其是30至45岁患者的治疗仍存在不足，包括成人诱导方案的持续高使用率、转介至临床试验的低比例以及黑人患者在骨髓移植方面的显著种族差异。
