Child Opportunity Index and Survival After Pediatric Hematopoietic Cell Transplantation for Acute Leukemia

Despite advances in pediatric hematopoietic cell transplantation (HCT) for acute leukemia, many children still experience relapse and non-relapse mortality (NRM). Whether neighborhood socioeconomic context is a risk factor in pediatric HCT remains unclear.

To evaluate the association between neighborhood opportunity, measured by the Child Opportunity Index (COI 3.0) and outcomes following first allogeneic HCT for pediatric acute leukemia.

We conducted a single-center retrospective cohort study of 147 children transplanted from 2012 to 2021. COI 3.0 is a validated composite measure of neighborhood-level resources and conditions capturing opportunities for child development. Primary analysis modeled COI as a five-level categorical exposure; exploratory analyses compared very low opportunity versus the remainder of the cohort. Outcomes included acute graft-versus-host disease (aGVHD), overall survival (OS), event-free survival (EFS), relapse, NRM, infections, and healthcare utilization.

In prespecified analyses, five-level neighborhood opportunity was not associated with clinical outcomes. In exploratory analyses, children in very low opportunity neighborhoods (N=30) experienced inferior OS compared with the remainder of the cohort (55% vs. 76%, p=0.01), after adjustment for detectable disease pre-HCT (adjusted HR 2.47, 95% CI 1.26-4.83, p=0.01). Relapse (37% vs. 28%) and NRM (10% vs. 7%) were higher among those in very low opportunity neighborhoods but were not statistically significant. No other differences were observed.

In this single-institution cohort, children from very low opportunity neighborhoods experienced inferior survival after HCT for acute leukemia in exploratory analyses. Neighborhood opportunity should be investigated in larger, multi-institutional cohorts as a clinical risk factor for poor outcomes.