PO.CL04.02 · 临床研究
社会健康决定因素对南加州队列中急性淋巴细胞白血病患儿生存的影响
Role of social determinants of health on survival in children with acute lymphoblastic leukemia in a Southern California cohort
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摘要 Abstract
中文摘要
目的：虽然急性淋巴细胞白血病（ALL）的生存率已有所提高，但结局差异依然存在，部分原因在于对社会健康决定因素（SDoH）的刻画有限以及少数族裔的参与度较低。我们评估了Rady儿童健康中心（2015-2023年）ALL青少年患者的临床结局和SDoH。
方法：我们评估了人口统计学、临床特征、结局以及父母的SDoH（语言、口译使用、文化适应、保险、社区脆弱性）。分析包括Kaplan-Meier法（5年无事件生存率EFS）、多变量logistic回归（校正比值比aOR）和Cox回归（校正风险比aHR），按年龄进行校正，按诊断年份聚类，并采用5000次自助法重抽样（bootstrap）。
结果：我们纳入了211名青少年，其中59%（n=124/211）为男性，64%（n=134/211）为白人，27%（n=56/211）为多种族，8%（n=16/211）为亚裔/太平洋岛民/美洲印第安人，2%（n=5/211）为黑人，55%（n=117/211）为西班牙裔。该队列的中位年龄为6岁，[四分位距IQR，4-13]，13%的青少年为15-18岁（n=28/211）。87%的患者（n=183/211）患有B-ALL[标危SR=57%（n=104/183），高危HR=35%（n=65/183），极高危VHR=8%（n=14/183）]；13%（n=28/211）患有T-ALL[标危+中危SR+IR=68%（n=19/28），高危HR=32%（n=9/28）]。8%的患者（n=17/211）复发一次，2%（n=4/211）复发两次。22%的患者（n=46/211）发生菌血症，1-4岁青少年中有28%入住ICU，而15-18岁青少年中为54%（P=0.039）。22%的父母（n=46/211）使用西班牙语进行医疗沟通。1-4岁青少年父母的口译使用率为85%，而15-18岁青少年为14%（P=0.001）。父母的文化适应程度因年龄而异：10-14岁青少年父母为36%，而15-18岁为29%（P=0.004）。公共保险对菌血症的aOR为3.31（95%CI 1.47-7.47）。菌血症与社区脆弱性无关（aOR 0.82，95%CI 0.34-1.96）。该队列的5年EFS为85.7%（标准误SE 2.8%），并因年龄和社区脆弱性（较高与较低相比）而异：在15-18岁中，EFS为57%对90%（高与低相比；P=0.036），在1-10岁中，EFS为78.9%对92.9%（高与低相比；P=0.001）。社区脆弱性对复发/死亡的aHR为2.87（95%CI 1.30-6.33）。
结论：在这个多样化的ALL队列中，我们发现了与年龄相关以及与SDoH相关的差异。青少年的生存率更差、ICU入住率更高、口译使用率更低。较高的社区脆弱性与死亡率增加独立相关，这凸显了为脆弱群体提供针对性支持的必要性。
查看英文原文 English abstract
PURPOSE: While survival for Acute lymphoblastic leukemia (ALL) has improved, outcome disparities remain, partly due to limited characterization of Social Determinants of Health (SDoH) and low participation of ethnic minorities. We evaluated clinical outcomes and SDoH in youth with ALL at Rady Children's Health (2015-2023).
METHODS: We assessed demographics, clinical characteristics, outcomes, and parental SDoH (language, interpretation use, acculturation, insurance, neighborhood vulnerability). Analyses included Kaplan-Meier (5-year EFS), multivariable logistic regression (aORs), and Cox regression (aHRs), adjusted by age, clustered by diagnosis year, with 5000 bootstrap replicates.
RESULTS: We included 211 youth, 59% (n=124/211) were male, 64% (n=134/211) were White, 27% (n=56/211) multiracial, 8% (n=16/211) Asian/Pacific Islander/American-Indian, 2% (n=5/211) Black, and 55% (n=117/211) Hispanic. The cohort's median age was 6 years (y), [IQR, 4-13], and 13% of youth was 15-18y (n=28/211). Eighty-seven percent of patients (n=183/211) had B-ALL [SR=57% (n=104/183), HR=35% (n=65/183), VHR=8% (n=14/183)]; and 13% (n=28/211) had T-ALL [SR+IR=68% (n=19/28), HR=32% (n=9/28)]. Eight percent of patients (n=17/211) relapsed once, and 2% (n=4/211) twice. Twenty-two percent of patients (n=46/211) developed bacteremia, and ICU admission occurred in 28% of youth 1-4y vs. 54% of youth 15-18y (P=0.039). Spanish for medical communication was used by 22% of parents (n=46/211). Interpretation use was 85% in parents of youth 1-4y vs. 14% of youth 15-18y (P=0.001). Parental acculturation differed by age: 36% in parents of youth 10-14y vs. 29% of 15-18y (P=0.004). The aOR of public insurance for bacteremia was 3.31 (95%CI 1.47-7.47). Bacteremia was not associated with neighborhood vulnerability (aOR 0.82, 95%CI 0.34-1.96). The cohort's 5-year EFS was 85.7% (SE 2.8%) and differed by age and neighborhood vulnerability (higher vs. lower): In 15-18y, EFS was 57% vs.90% (high vs. low; P=0.036), and in 1-10y, EFS was 78.9% vs.92.9% (high vs. low; P=0.001). The aHR of neighborhood vulnerability for relapse/death was 2.87 (95%CI 1.30- 6.33).
CONCLUSION: In this diverse ALL cohort, we found age-related and SDoH-associated disparities. Adolescents had worse survival, more ICU admissions, and lower interpreter use. Higher neighborhood vulnerability was independently linked to increased mortality, underscoring the need for targeted support for vulnerable groups.
利益披露 Disclosure
D. Lee, None..
A. Rios, None..
D. Kuo, None..
V. Wong, None..
A. P. Ganesan, None..
W. Roberts, None..
O. Ramirez, None..
P. Aristizabal, None.