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Poverty and Targeted Immunotherapy: Survival in Children's Oncology Group Clinical Trials for High-Risk Neuroblastoma
Kira Bona1, Yimei Li2, Lena E Winestone3
1Department of Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
Insights
Poverty, particularly household poverty, is linked to worse survival outcomes in children with high-risk neuroblastoma treated with immunotherapy. Addressing social determinants of health may improve targeted therapy effectiveness.
Area of Science:
- Pediatric Oncology
- Social Determinants of Health
- Immunotherapy
Background:
- The association between social determinants of health and survival in pediatric oncology immunotherapy trials is unknown.
- This study investigates the impact of poverty on event-free survival (EFS) and overall survival (OS) in children with high-risk neuroblastoma.
- Poverty is a key social determinant of health that can influence health outcomes.
Purpose of the Study:
- To examine the association between poverty and survival outcomes in pediatric patients undergoing targeted immunotherapy for high-risk neuroblastoma.
- To determine if neighborhood or household poverty independently affects EFS and OS.
- To explore the combined impact of neighborhood and household poverty on survival.
Main Methods:
- Retrospective cohort study of 371 children with high-risk neuroblastoma treated with GD2-targeted immunotherapy (2005-2014).
- Neighborhood poverty defined by zip code median household income (lowest quartile).
- Household poverty defined by sole public insurance coverage. Multivariable Cox regression analysis was used.
Main Results:
- Household poverty was independently associated with significantly inferior EFS (HR=1.90) and OS (HR=2.79).
- Neighborhood poverty was not independently associated with EFS or OS.
- Children with both neighborhood and household poverty experienced significantly inferior EFS (HR=2.21) and OS (HR=3.70) compared to the unexposed group.
Conclusions:
- Poverty is independently associated with an increased risk of relapse and death in neuroblastoma patients receiving targeted immunotherapy.
- Social and environmental factors, such as poverty, should be considered in future clinical trials.
- Targeting social determinants of health may enhance the efficacy of immunotherapy in pediatric oncology.
Background:
Whether social determinants of health are associated with survival in the context of pediatric oncology-targeted immunotherapy trials is not known. We examined the association between poverty and event-free survival (EFS) and overall survival (OS) for children with high-risk neuroblastoma treated in targeted immunotherapy trials.
Methods:
We conducted a retrospective cohort study of 371 children with high-risk neuroblastoma treated with GD2-targeted immunotherapy in the Children's Oncology Group trial ANBL0032 or ANBL0931 at a Pediatric Health Information System center from 2005 to 2014. Neighborhood poverty exposure was characterized a priori as living in a zip code with a median household income within the lowest quartile for the cohort. Household poverty exposure was characterized a priori as sole coverage by public insurance. Post hoc analyses examined the joint effect of neighborhood and household poverty using a common reference. All statistical tests were 2-sided.
Results:
In multivariable Cox regressions adjusted for disease and treatment factors, household poverty-exposed children experienced statistically significantly inferior EFS (hazard ratio [HR] = 1.90, 95% confidence interval [CI] = 1.28 to 2.82, P = .001) and OS (HR = 2.79, 95% CI = 1.63 to 4.79, P < .001) compared with unexposed children. Neighborhood poverty was not independently associated with EFS or OS. In post hoc analyses exploring the joint effect of neighborhood and household poverty, children with dual-poverty exposure (neighborhood poverty and household poverty) experienced statistically significantly inferior EFS (HR = 2.21, 95% CI = 1.48 to 3.30, P < .001) and OS (HR = 3.70, 95% CI = 2.08 to 6.59, P < .001) compared with the unexposed group.
Conclusions:
Poverty is independently associated with increased risk of relapse and death among neuroblastoma patients treated with targeted immunotherapy. Incorporation of social and environmental factors in future trials as health-care delivery intervention targets may increase the benefit of targeted therapies.
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