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 United States, but the duration of impact after ALL diagnosis is not well understood. This retrospective cohort study used the National Cancer Database to evaluate 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 2 and 5 years from diagnosis. This cohort of 17 044 children with ALL consisted of 57% males, 61% non-Hispanic White, 24% Hispanic, 8% non-Hispanic Black, 5% Asian, and 2% other race/ethnicities. Furthermore, 12% (1971) resided in the lowest SES neighborhoods, whereas 18% resided in the highest SES neighborhoods. Compared with those in the highest SES neighborhoods, children in the lowest SES neighborhoods had a 55% increased hazard of all-cause mortality (95% confidence interval [CI], 1.29-1.88; P < .001). The increased hazard of mortality among those from the lowest SES neighborhoods persisted among those who survived 2 years (hazard ratio [HR], 1.70; 95% CI, 1.28-2.26; P = .001) and 5 years (HR, 1.87; 95% CI, 1.17-3.00; P = .032) after ALL diagnosis. These findings suggest the need for long-term strategies to support at-risk patients beyond completion of frontline therapy.