Chronic Myelogenous Leukemia: Poverty Based Disparities in Survival Open Access

Abstract

Chronic myelogenous leukemia (CML) is a myeloproliferative neoplasm characterized by a pathogenic gene known as the Philadelphia or Ph chromosome which results in oncogene BCR-ABL1. The Philadelphia chromosome provides a great target for treatment, and tyrosine kinase inhibitors introduced in the early 2000s have brought 5-year survival of CML to nearly 90% in clinical trials. However, epidemiologic studies place 5-yr relative survival of CML in the US at 70% for 2010–2016 calendar period. There is currently little published data on what role poverty or SES plays in CML disparities. As research has shown that not all individuals receive therapy equally, individuals in poverty with limited access to care may not be benefiting as fully from the availability of TKI treatment and therefore experience worse outcomes. This analysis of the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program found that there is a negative correlation between living in high poverty rate areas (greater than 20% of individuals under the poverty line) and CML survival time compared to cases living in low poverty areas (HR = 1.52; 95% CI 1.13-2.05). This is consistent with prior studies demonstrating increased cancer mortality in high poverty areas. Survival disparities in CML between low and high poverty areas may be mediated by limited access to tyrosine kinase inhibitors: an effective and well tolerated targeted treatment for CML. Cost and inaccessibility may lead to lower rates of TKI utilization in low SES patients.

Table of Contents

Table of Contents

CHAPTER PAGE

Chapter I: Background/Literature Review .......................................................................................1

Introduction .................................................................................................1

Risk Factors for CML Survival Outcomes .................................................3

Poverty Rate and CML Outcomes ..............................................................5

Chapter II: Manuscript .....................................................................................................................8

Introduction .............................................................................................................8

Methods.................................................................................................................11

Study Population .......................................................................................11

Exposure Variable ....................................................................................11

Covariates ................................................................................................12

Outcome of Interest ..................................................................................12

Statistical Analysis ....................................................................................13

Results ...................................................................................................................14

Sensitivity Analysis ..................................................................................16

Discussion .............................................................................................................17

Strengths and Limitations .........................................................................20

References .............................................................................................................23

Tables ....................................................................................................................28

Table 1 ......................................................................................................28

Table 2 ......................................................................................................29

Table 3 ......................................................................................................30

Figures...................................................................................................................31

Figure 1 .....................................................................................................31

Figure 2 .....................................................................................................32

Chapter III: Future Directions .......................................................................................................33

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology
Keyword	CML SES Leukemia Chronic Myelogenous Leukemia Survival Analysis Poverty
Committee Chair / Thesis Advisor	Kevin Ward, Emory University

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