Among children receiving maintenance therapy for acute lymphoblastic leukemia (ALL), those living in extreme poverty had a nearly 2-fold greater risk of relapse than those not living in extreme poverty, according to research published in Blood.

Researchers conducted a secondary analysis of the COG-AALL03N1 trial ( Identifier: NCT00268528), which was designed to examine adherence to mercaptopurine maintenance among children with ALL.

A total of 592 patients (68.4% male) were included in the analysis. The median age was 5 years (range, 1-19 years) at ALL diagnosis and 6 years (range, 2-21 years) at study enrollment. The median follow-up was 7.9 years (range, 0.1-13 years).

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The researchers found that 12.3% of patients were living in extreme poverty, which was defined as the federal poverty threshold being above 120% of their yearly household income.

At 3 years from study enrollment, the cumulative incidence of relapse among patients living in extreme poverty was significantly higher than among patients not living in extreme poverty (14.3% and 7.6%, respectively; P =.04).

In a model adjusted for age at study enrollment, National Cancer Institute risk group, blast cytogenetics, and time from maintenance, the risk of relapse for children living in extreme poverty was roughly twice as high as for those not living in extreme poverty (hazard ratio [HR], 1.95; 95% CI, 1.03-3.72; P =.04).

Including race/ethnicity or parental education level in the model attenuated the effect of extreme poverty (race/ethnicity HR, 1.68; 95% CI, 0.86-3.28; P =.1; education HR, 1.69; 95% CI, 0.84-3.41; P =.1).

Further analysis of factors that may contribute to relapse risk revealed that children living in extreme poverty were more likely than those not living in extreme poverty to be nonadherent to mercaptopurine (57.1% and 40.9%, respectively; P =.04). However, the researchers found that nonadherence resulted in minimal attenuation of the association between poverty and relapse risk.

“These data, along with our results showing greater proportion of patients living in extreme poverty who are unable to maintain critical adherence at a level of 95%, indicate that nonadherence to chemotherapy may partly explain the greater number of early relapses,” the researchers wrote. “Future studies should implement screening measures for poverty and assist families with resources that ameliorate these financial hardships.”

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


Wadhwa A, Chen Y, Hageman L, et al. Poverty and relapse risk in children with acute lymphoblastic leukemia: a Children’s Oncology Group study AALL03N1 report. Blood. 2023;142(3):221-229. doi:10.1182/blood.2023019631

This article originally appeared on Hematology Advisor