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Evidence for under-diagnosis of childhood acute lymphoblastic leukaemia in poorer communities within Great Britain
M E Kroll1, C A Stiller, S Richards
1Childhood Cancer Research Group, Department of Paediatrics, University of Oxford, UK. mary.kroll@ceu.ox.ac.uk
Insights
Childhood acute lymphoblastic leukaemia incidence is lower in poorer communities. This study suggests under-diagnosis due to infection may explain this, impacting public health strategies.
Area of Science:
- Pediatric Oncology
- Epidemiology
- Health Disparities
Background:
- Childhood acute lymphoblastic leukaemia (ALL) incidence is lower in socioeconomically disadvantaged communities.
- The preemptive infection hypothesis suggests some ALL cases are undiagnosed due to fatal infections.
- Untreated ALL can manifest with various blood abnormalities.
Purpose of the Study:
- To investigate the socioeconomic variation in childhood ALL incidence.
- To test the hypothesis that under-diagnosis in poorer communities contributes to observed incidence disparities.
Main Methods:
- Logistic regression analysis of pre-treatment blood counts from 5601 children in national ALL trials (1980-2002).
- Children were grouped by deprivation quintiles using the 1991 Carstairs index.
- Identified children with neutropenia and normal hemoglobin/platelets as potentially at risk of non-diagnosis.
Main Results:
- A significant deficit of children at risk of non-diagnosis was observed in poorer communities (P(trend)=0.004).
- Conversely, an excess of children with pallor (P(trend)=0.045) and bleeding (P(trend)=0.036) was found in these communities.
- Findings support the hypothesis of under-diagnosis in socioeconomically deprived populations.
Conclusions:
- Under-diagnosis of childhood ALL in poorer communities may contribute to socioeconomic disparities in recorded incidence.
- Results have implications for clinical practice, emphasizing thorough diagnosis in vulnerable populations.
- Further epidemiological studies should account for potential under-diagnosis in socioeconomic analyses.
Background:
Recorded incidence of childhood acute lymphoblastic leukaemia tends to be lower in poorer communities. A 'preemptive infection hypothesis' proposes that some children with leukaemia die from infection without diagnosis of leukaemia. Various different blood abnormalities can occur in untreated leukaemia.
Methods:
Logistic regression was used to compare pre-treatment blood counts among children aged 1-13 years at recruitment to national clinical trials for acute lymphoblastic leukaemia during 1980-2002 (N=5601), grouped by address at diagnosis within Great Britain into quintiles of the 1991 Carstairs deprivation index. Children combining severe neutropenia (risk of serious infection) with relatively normal haemoglobin and platelet counts (lack of pallor and bleeding) were postulated to be at risk of dying from infection without leukaemia being suspected. A deficit of these children among diagnosed patients from poorer communities was predicted.
Results:
As predicted, there was a deficit of children at risk of non-diagnosis (two-sided P(trend)=0.004; N=2009), and an excess of children with pallor (P(trend)=0.045; N=5535) and bleeding (P(trend)=0.036; N=5541), among cases from poorer communities.
Conclusion:
Under-diagnosis in poorer communities may have contributed to socioeconomic variation in recorded childhood acute lymphoblastic leukaemia incidence within Great Britain, and elsewhere. Implications for clinical practice and epidemiological studies should be considered.
