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Updated: May 5, 2026
Murine Model of Leukemia Relapse to Induction Chemotherapy for Acute Lymphoblastic Leukemia
Published on: October 17, 2025
Patient and hospital factors associated with induction mortality in acute lymphoblastic leukemia
Alix E Seif1, Brian T Fisher, Yimei Li
1Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Insights
Induction deaths in pediatric acute lymphoblastic leukemia (ALL) are low but increase significantly with organ failure. Hospital payer mix impacts ALL induction mortality, highlighting variation across institutions.
Area of Science:
- Pediatric Oncology
- Hematology
- Healthcare Management
Background:
- Induction chemotherapy for pediatric acute lymphoblastic leukemia (ALL) carries significant mortality risk.
- Deaths during induction chemotherapy represent a substantial portion of ALL-associated and treatment-related mortality.
- Identifying factors associated with induction mortality is crucial for improving patient outcomes.
Purpose of the Study:
- To investigate patient- and hospital-level factors linked to induction mortality in pediatric ALL.
- To analyze the association between socioeconomic status, interventions, and hospital characteristics with induction death rates.
- To establish benchmarks for attainable induction mortality rates.
Main Methods:
- Retrospective cohort analysis of 8,516 children with newly diagnosed ALL (0-19 years) from 1999-2009.
- Utilized the Pediatric Health Information System database from US children's hospitals.
- Employed Cox regression and multiple linear regression to model induction mortality risk and hospital-level factors.
Main Results:
- Overall ALL induction mortality was 1.12%.
- Mechanical ventilation and vasoactive infusions significantly increased mortality risk (HR 122.30).
- Hospitals with the highest mortality quartiles had disproportionately more deaths; hospital payer mix correlated with induction mortality (P=0.046).
Conclusions:
- While overall induction death risk is low, it rises sharply with cardio-respiratory and organ failure.
- Significant variation in induction mortality exists across hospitals, linked to payer mix.
- Improving outcomes in high-mortality hospitals and aiming for <1% national induction mortality are key goals.
Background:
Deaths during induction chemotherapy for pediatric acute lymphoblastic leukemia (ALL) account for one-tenth of ALL-associated mortality and half of ALL treatment-related mortality. We sought to ascertain patient- and hospital-level factors associated with induction mortality.
Procedure:
We performed a retrospective cohort analysis of 8,516 children ages 0 to <19 years with newly diagnosed ALL admitted to freestanding US children's hospitals from 1999 to 2009 using the Pediatric Health Information System database. Induction mortality risk was modeled accounting for demographics, intensive care unit-level interventions, and socioeconomic status (SES) using Cox regression. The association of ALL induction mortality with hospital-level factors including volume, hospital-wide mortality and payer mix was analyzed with multiple linear regression.
Results:
ALL induction mortality was 1.12%. Race and patient-level SES factors were not associated with induction mortality. Patients receiving both mechanical ventilation and vasoactive infusions experienced nearly 50% mortality (hazard ratio 122.30, 95% CI 66.56-224.80). Institutions in the highest induction mortality quartile contributed 27% of all patients but nearly half of all deaths (47 of 95). Hospital payer mix was associated with ALL induction mortality after adjustment for other hospital-level factors (P = 0.046).
Conclusions:
The overall risk of induction death is low but substantially increased in patients with cardio-respiratory and other organ failures. Induction mortality varies up to three-fold across hospitals and is correlated with hospital payer mix. Further work is needed to improve induction outcomes in hospitals with higher mortality. These data suggest an induction mortality rate of less than 1% may be an attainable national benchmark.
