Children with acute lymphoblastic leukemia (ALL) in maintenance therapy were at an increased risk of relapse if they lived in extreme poverty. Living in extreme poverty was also associated with nonadherence to mercaptopurine maintenance therapy, but did not entirely explain the association between relapse and extreme poverty, according to a report published in Blood.

A secondary analysis of 592 patients in first remission entering maintenance therapy from the COG-AALL03N1 trial ( identifier: NCT00268528) was conducted and included data from the United States Census Bureau to identify individuals living in different poverty conditions. Extreme poverty was considered those who lived at 120% below the federal poverty threshold.

The COG-AALL03N1 trial evaluated the use of 6-mercaptopurine as maintenance therapy for patients aged 21 or younger with ALL in first remission.

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The median age of the cohort was 5 years (range, 1-19) and 68.4% of patients were male. There were 35.0% of patients who were Hispanic, 32.4% who were non-Hispanic White, 18.2% who were African American or Black, and 14.4% who were Asian. Parents completed up to a high school education in 34.6% of cases. The median number of individuals in the household was 4 with a median of 2 children.

There were 12.3% of patients living in extreme poverty, which was significantly associated with non-White race/ethnicity (P ≤.01) and high school level or lower education level (P <.001).

The cumulative incidence of relapse by 3 years was significantly higher among patients living in extreme poverty at 14.3% compared with 7.6% among patients not living in extreme poverty (hazard ratio [HR], 7.6%; 95% CI, 5.5-10.1; P =.04).

This association remained apparent in a multivariate analysis, in which there was a 1.95-fold greater risk of relapse among children living in extreme poverty compared with other conditions (95% CI, 1.03-3.72; P =.04). However, the association was not significant after adjustment by race/ethnicity (HR, 1.68; 95% CI, 0.86-3.28; P =.1) or by education level (HR, 1.69; 95% CI, 0.84-3.41; P =.1).

Adherence to mercaptopurine was lower among patients living in extreme poverty, with 57.1% of patients nonadherent compared with 40.9% living in other conditions (P =.04).

“Future studies should implement screening measures for poverty and assisting families with resources that ameliorate these financial hardships,” the authors concluded in their report.

Disclosures: One study author declared affiliations with biotech, pharmaceutical, or device companies. Please see the original reference for a full list of disclosures.


Wadwha A, Chen Y, Hageman L, et al. Poverty and relapse risk in children with acute lymphoblastic leukemia: Children’s Oncology Group Study AALL03N1 Report. Blood. Published online April 17, 2023. doi: 10.1182/blood.2023019631

This article originally appeared on Hematology Advisor