Sociodemographic determinants of survival in acute lymphoblastic leukemia: A 20-year SEER-based analysis

Abstract

Abstract Introduction Despite significant advancements in therapeutic strategies, acute lymphoblastic leukemia (ALL) continues to present a challenge with variable survival outcomes across diverse patient populations. It is increasingly evident that factors beyond clinical variables such as age, sex, race, income, and geographic location, play a critical role in determining prognosis. This study evaluates the impact of these factors on overall survival (OS) in patients with ALL using the SEER dataset. Methods Data were extracted from the SEER database (2002–2022) for patients diagnosed with ALL. Cases with incomplete survival data or missing key demographic variables were excluded. Variables included in the analysis were age, sex, race, household income (low <$50,000, mid $50,000–$74,999, and high ≥$75,000 income tiers), and geographic location. We used Kaplan-Meier survival curves to estimate the median survival time and multivariable Cox proportional hazards model to identify independent predictors of mortality. Result A total of 4,943 patients met inclusion criteria. The cohort was 56.6% male and 43.4% female. The majority of patients were White (77.3%), followed by Asian or Pacific Islander (11.9%), Black (7.4%), American Indian/Alaska Native (2.3%), and Unknown (1.1%). Most patients were aged 10–19 years (27.4%), 60–69 (12.9%), 50–59 (12.7%), with 11.9% aged 20–29 years. The median overall survival (OS) was 67 months. On Kaplan-Meier analysis, OS declined with age, from 43.0 months (95% CI: 33.0–56.0) in patients aged 40–49 to 2.0 months (95% CI: 2.0–3.0) in those ≥80. Median OS was 80.0 months (95% CI: 64.0–112.0) in males vs 58.0 months (95% CI: 49.0–79.0) in females. Patients in high-income areas had a median OS of 76.0 months (95% CI: 65.0–100.0) compared to 48.0 months (95% CI: 36.0–81.0) in mid-income areas. Among racial groups, Black patients had the shortest OS (33.0 months, 95% CI: 27.0–49.0), though race was not significant in adjusted models. On multivariable Cox regression, older age remained the strongest predictor of mortality. HR 1.54 (95% CI: 1.28–1.84) for age 40–49 and HR 7.90 (95% CI: 6.60–9.45) for age ≥80 (p < 0.001 for all). Male sex (HR: 1.10; 95% CI: 1.02–1.20; p = 0.018) and low income (HR: 1.29; 95% CI: 0.90–1.84; p = 0.165) were associated with worse outcomes, while high income was associated with better outcomes (HR: 0.90; 95% CI: 0.82–1.00; p = 0.045). Race and metropolitan residence were not independently associated with OS in the adjusted model.Conclusion In this population-based analysis of patients with ALL, older age, male sex, and lower income were independently associated with worse overall survival. While descriptive differences in survival were observed by race and geographic region, these factors were not statistically significant after adjustment. The findings highlight the critical role of age and socioeconomic status as determinants of ALL outcomes and underscore the need for targeted interventions to address these persistent disparities in care.