Survival disparities by race and income among adolescents and young adults with acute lymphoblastic leukemia

Abstract Background: Since 2012, the adoption of pediatric-inspired regimens, the integration of tyrosine kinase inhibitors (TKIs) and immunotherapies, and the use of measurable residual disease (MRD)-guided strategies have substantially improved survival for adolescents and young adults (AYAs) with acute lymphoblastic leukemia (ALL), with current protocols achieving long-term survival rates approaching those seen in pediatric populations. However, it is unclear if these improvements have benefited all patient groups equally. To address this, we analyzed Surveillance, Epidemiology, and End Results (SEER) program data to evaluate trends in five-year overall survival (OS) by race, sex, and household income across two treatment eras (2000–2012 and 2013–2016). Methods: We conducted a retrospective analysis using the SEER program, which collects comprehensive cancer data from multiple regions and covers nearly 30% of the U.S. population. SEER provides detailed information on demographics, socioeconomic status, and survival outcomes. We identified all AYAs (age 15–39) diagnosed with ALL from 2000 to 2016. The study period was split into two eras: 2000–2012 and 2013–2016. Five-year OS and 95% confidence intervals (CIs) were estimated using Kaplan–Meier analysis, with group comparisons via log-rank test. Results: We identified 6,531 AYA patients with ALL. Five-year OS improved in the modern era, climbing from 53.1% to 66.3% for females and from 53.5% to 66.9% for males. Survival difference was not statistically significant between sexes (p=0.40). Between 2000–2012, OS for White and Black patients was 54.1% vs 46.6% respectively and not significantly different. Between 2013–2016, although five-year OS increased to 66.6% (95% CI: 64.3–68.8) for White patients, Black patients saw only 54.9% (46.6–62.6) (p=0.006). In 2013–2016, patients in the high-income group (>$100,000) had the best five-year OS at 76.7% (95% CI: 72.1–80.7, N=542), compared to 65.0% (95% CI: 62.7–67.3, N=2325) in the middle-income group ($50,000–$100,000) and 55.4% (95% CI: 42.9–66.1, N=90) in the low-income group (<$50,000). The survival difference between high and low-income groups was statistically significant in 2013–2016 (log-rank p = 0.00005). In the earlier era (2000–2012), 5-year OS was lower overall and differences between income groups did not reach statistical significance (Low: 49.7% [95% CI: 40.1–58.5, N=115]; Middle: 53.3% [51.4–55.1, N=2915]; High: 54.2% [49.6–58.5, N=496]; log-rank p = 0.21). Among White patients, high-income patients had much better survival than low-income (75.8% [70.3–80.5] vs 60.9% [46.7–72.5], p=0.019), a difference that was not present in earlier years (54.8% vs 52.6%, p=0.38). Conclusion: Survival has improved for AYAs with ALL, but not everyone has benefited equally. Racial and income-based gaps exist, especially among Black and low-income patients. These results highlight a real need for targeted efforts to address these widening survival disparities.