Role of social determinants of health on survival in children with acute lymphoblastic leukemia in a Southern California cohort

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.