Poor community health status correlated with an increased risk for nonrelapse mortality (NRM) following allogeneic hematopoietic cell transplantation (HCT), according to findings from a retrospective study published in Cancer. Although suboptimal community health and health care resources were found to negatively affect survival, prompting a patient’s community health status to emerge as a potential prognostic factor, the community health status of the transplant center location was not found to affect patient outcomes.1

The study was conducted by Sanghee Hong, MD, of the Blood and Marrow Transplant Program in Cleveland Clinic’s Taussig Cancer Institute, and an international group of researchers who investigated the link between community factors and patient survival post HCT. Although HCT has been associated with disparities in patient access to transplantation in the past,2,3 “the impact of health disparities as determined by community factors on allogeneic HCT outcomes is less clear and has been only partially described with sociodemographic factors such as race, ethnicity, and income,” the study authors stated.1

To facilitate the analysis, the investigators used 2018 data from the County Health Rankings and Roadmaps (CHRR) project, which ranks US counties in each state based on a variety of health measures and generates a county-specific Health Factors summary score. The score is a weighted composite of 4 components: health behaviors, clinical care, social and economic environment, and physical environment. Across these 4 categories, the CHRR scoring system accounts for rates of adult smoking and obesity, sexually transmitted diseases, lack of insurance, and preventable hospital stays, as well as the availability of primary health care providers, among other factors. 

The investigators procured patient- and transplant center-specific composite scores for 18,544 patients who underwent primary HCT between 2014 and 2016 in the United States. Patient data were extracted from the Center for International Blood and Marrow Transplant Research’s 2018 Center-Specific Survival Analysis dataset. For most measures, a higher score reflected worse health factors.

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The study’s primary objective was to examine links between the community of residence with patient survival time, relapse, and death from causes other than relapse. The investigators also assessed whether the health score of the community where the patient resided (patient community risk score; PCS) and the score of the community where the transplant center was located (center community risk score; CCS) could predict 1-year survival.

In a Cox regression multivariable analysis, a higher PCS was associated with inferior overall survival (OS), translating to a hazard ratio (HR) per 1 standard deviation (SD) increase in PCS of 1.04 (99% CI, 1.00-1.08; P =.0089). The CCS, however, “was not significantly associated with OS,” the investigators said (HR, 1.01; 99% CI, 0.98-1.04; P =.54).

The trend seen with elevated PCS and suboptimal OS extended to a subgroup analysis of 17,793 patients with hematologic malignancies. In this subset, the HR per 1 standard deviation increase in PCS (1.04) was the same as that seen in the general analysis (99 %, 1.00-1.08; P =.0102). “As in the analysis of all patients, we observed no association of CCS with OS, NRM, or relapse among HCT recipients with hematologic malignancies,” the authors wrote.

The investigators identified several study limitations, including the possibility that a small number of patients moved from their original places of residence during the post-HCT period. The evaluation of disparity-related components at the county vs zip code level was another restrictive factor.

Nevertheless, “the association between the community health status of a patient’s residence and his or her survival and risk of NRM supports our hypothesis that worse community health and health care resources surrounding a patient’s residence negatively influence the post-HCT course,” the study authors stated. Although more studies are needed to characterize the disparities seen in this analysis, the investigators posited that “patients from communities with inadequate resources, reflected by a worse PCS, likely need resources and attention to overcome this additional risk.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of the authors’ disclosures.


  1. Hong S, Brauzauskas R, Hebert KM et al. Community health status and outcomes after allogeneic hematopoietic cell transplantation in the United States. Cancer. Published online October 21, 2020. doi:10.1002/cncr.33232
  2. Majhail NS, Nayyar S, Santibanez ME, Murphy EA, Denzen EM. Racial disparities in hematopoietic cell transplantation in the United States. Bone Marrow Transplant. 2012;47(11):1385-1390. doi:10.1038/bmt.2011.214
  3. Majhail NS, Omondi NA, Denzen E, Murphy EA, Rizzo JD. Access to hematopoietic-cell transplantation in the United States. Biol Blood Marrow Transplant. 2010;16(8):1070-1075. doi:10.1016/j.bbmt.2009.12.529