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Mitigating the Effects of Neighborhood Disadvantage in Acute Myeloid Leukemia: Brittany Ragon, MD

  At the recent American Society of Hematology (ASH) Annual Meeting, Dr. Brittany Ragon, Adult Leukemia and Transplant Specialist at Levine Cancer Institute, sat down with Oncology Data Advisor to discuss her presentation on neighborhood disadvantages associated with inferior overall survival outcomes for patients with acute myeloid leukemia (AML). In addition, Dr. Ragon shares the efforts that are underway to design interventions that address outcomes disparities experienced by these patients.

 Oncology Data Advisor: Welcome to Oncology Data Advisor. I'm Keira Smith. Today, we're here at the ASH Annual Meeting in San Diego, and I'm joined by Dr. Brittany Ragon. Thanks much for coming on today.

Brittany Ragon, MD: Thanks for having me.

Oncology Data Advisor: To start off, would like to introduce yourself and share a little bit about what you do in your work?

Dr. Ragon: Sure, I'm Dr. Brittany Ragon. I'm an Adult Leukemia and Transplant Specialist in Charlotte, North Carolina. I work at Levine Cancer Institute. My focus is in a lot of things, but AML is a passion point of mine—not only some of the clinical interventions we can do, but also a lot of the outcomes-based interventions and analyses I like to do as well.

Oncology Data Advisor: Awesome. Today, we're talking about your presentation on neighborhood disadvantages associated with inferior overall survival for AML patients treated with standard intensive induction. For a little bit of background, what are some of the known biologic and socioeconomic factors that contribute to outcome disparities in AML?

Dr. Ragon: It's a really complex issue because there's a lot involved in outcomes for acute myeloid leukemia. This abstract is highlighting some of the socioeconomic factors that are involved with outcome disparities, but they all sort of play into it together. We know a lot about the biologic factors that influence risk categories for patients. What we just don't know enough about is how social determinants of health and how a person's race or ethnicity can play into outcomes.

It's important to sort of have a background of something that happened at the plenary session in ASH of December 2020. Dr. Bhavana Bhatnegar presented her work on the fact that Black patients had an inferior overall survival compared to White patients, and that was the greatest independent risk factor for poor survival. That was a really striking abstract. At that same ASH, Dr. Irum Khan, who I consider a real expert in this work, also presented about structural racism as a mediator of outcome disparity in acute myeloid leukemia. A lot of our work is really on the shoulders of their work in trying to identify or understand those aspects in our population in Charlotte and in North Carolina.

Oncology Data Advisor: To speak about the study that you have here, why did you decide to focus specifically on the impact of neighborhood disadvantage on survival in AML?

Dr. Ragon: Great question. To tie into my prior background, after we saw the great work that they were doing with the CIRI Alliance data and the great work that they were doing in the Chicago Consortium, we wanted to understand our population as well. At our institution, we were already looking at these types of disparities in our lymphoma and myeloma disease cohorts. Interestingly enough, we weren't seeing a lot of racial differences in outcomes. By that point, our institution was a bit more mature, and our data was a bit more mature, so we were able to look at the impact of race and ethnicity on outcomes in acute myeloid leukemia.

We actually presented some of this work last year. At the time, we only had access to census track data. What we found last year was that we didn't see that survival difference in patients who were Black compared to White patients in our AML population. Now, that wasn't a very stratified cohort. That was just all patients coming to our institution. This year, we wanted to dive a little deeper. Now we had access to the area deprivation index (ADI). The area deprivation index is something that assesses socioeconomic factors of a community. It looks at income, education status—and these are technically theoretical—housing quality, employment. Those factors are all taken together into this area deprivation index. Now we had access to this data.

We also had access to the types of therapies our patients received. We wanted to take a look at that younger population. We looked at all patients, but we wanted to take a look at that intensive induction-based younger cohort to see, okay, do we see a difference based on neighborhood advantage or disadvantage? That's kind of how it came to be. Of course, there's a whole lot more to learn.

Oncology Data Advisor: Awesome, thanks for explaining all the background for it. What did the study show?

Dr. Ragon: We looked at about 380 patients. This was from a time span from 2015 to 2020. This time, we actually eliminated patients who had acute promyelocytic leukemia (APL), because that's a very distinct cohort that probably behaves differently. We were looking at the non-APL AML patients. Once again, we didn't see a great difference in survival based on ethnic or racial groups, but we did see a significant difference in survival based on neighborhood disadvantage in the ADI.

We saw that patients who had greater neighborhood disadvantage had an inferior survival compared to those who had greater advantage. That was the most important outcome that we identified. That's the one that we were expecting to identify, but we took it a bit further. We have a really unique nurse navigation program, a tremendous one, and we've had it for years. There are AML-specific and leukemia-specific nurse navigators, which helps. They touch base with every patient. They identify some of those aspects of the social determinants of health, such as transportation, compliance, emotional factors, and housing. They assess patients, they meet with patients, they determine what some of the challenges are, and then they create an acuity score. That determines how often they touch base with patients and some of the interventions that they're able to provide patients.

We were able to include some of the data that they offer us. That was another layer of our analysis. One of the things we identified was that for patients of greater disadvantage, the thing that they reported more often than patients of greater advantage was that transportation was a major issue. Transportation is a major issue for all patients, but it seemed to be more so for those with greater neighborhood disadvantage, which you would think makes sense, but we were able to spell it out clearly. This is regardless of our nurse navigators giving travel grants and travel assistance. It's not just about giving someone a transportation card. It's more than that, right? Those are the things that we're trying to understand better.

The other thing that we identified was that patients of greater advantage were more likely to go on to stem cell transplant than those of greater disadvantage. Stem cell transplant may be the great leveler of outcomes. We are working to explore that more. It's not just about insurance. The insurance status didn't make a difference in outcomes. Some would think, well, if you don't have insurance, you don't have access to transplant, but it goes beyond that. Ultimately, a big conclusion is that access to transplant plays a big role in survival as well.

Oncology Data Advisor: Absolutely. It's definitely exciting to hear about the nurse navigation program. I'm sure it's very unique that it's leukemia-specific. That's amazing to see how it plays a role in outcomes.

Dr. Ragon: It's incredibly important to us. Other institutions have it as well, but I think that it is a modifiable intervention that we can potentially offer patients. It's not perfect, but it's a step in the right direction.

Oncology Data Advisor: In light of these results that the study showed about neighborhood disadvantage and access to stem cell transplant, what changes are needed to overcome the detrimental impact of these disparities on AML outcomes?

Dr. Ragon: think we need to understand them more, highlighting them and calling them out. There is an interesting abstract that's being presented on Monday actually. When we think about racial and ethnic disparities, such as the abstract that I highlighted from Dr. Bhatnegar that she presented in December of 2020, there's another abstract that's looking at the Flatiron health data, a big database of AML patients. From 2014 to 2018, they did see inferior survival for Black patients, but from 2018 on, that disparity sort of went away or leveled out.

Something has changed, and I think part of that change is awareness. Awareness is one thing, but also once we can suggest and identify possible factors, we should design interventions. There should be more interventional prospective trials in this space because these are potentially modifiable risk factors, and it's complex. There's policy involved, and there are potential biologic mechanisms involved. There's a lot of historical structural racism and systemic disadvantage involved.

There's just so much work to be done, so I think we're going to have to be a bit bold and think about using things like nurse navigation and financial interventions. I think you spoke with one of my colleagues, Greg Knight, here. He's done prospective interventions for patients with financial toxicity and financial distress, where we get financial advisors pro bono who help counsel patients. Things like that are absolutely going to be required to have an impact here. It's a global front; it's not just the scientific research. It's policy, advocacy, calling out what we see, identifying structural racism, taking out bias. There are a lot of things that are going to be involved in making a difference here and many years of work ahead.

Oncology Data Advisor: Absolutely, and all these avenues and these creative ways to approach it are making a difference.

Dr. Ragon: I will say one other thing that does make me lose sleep at night is all the patients that we don't meet. When we think about disadvantage, there's likely a huge, disadvantaged population who never make it to our door. How we capture those patients and find them and potentially give them a chance, that's a real passion point. That's going to take a lot of work from a lot of people, so I think that's part of the future of this as well.

Oncology Data Advisor: For sure. What are your next steps planned for this study?

Dr. Ragon: One piece of the research that's not quite done is that we had planned upfront to not just look at the social determinants of health but also at some of the biologic influences. There's something called single nucleotide polymorphisms. We know that there are sometimes racial and ethnic differences in these snips that could play a role in the metabolism of some of the agents that we use.

There's another great abstract that was presented at this ASH looking at a pediatric AML cohort where they use this multigene panel, this ACS-10, and it allowed them to determine whether a Black patient should get a less-intensive or a higher-intensity regimen to help improve their outcomes.

We would like to find something similar by looking at the single nucleotide polymorphisms, because if there's a difference in how they're metabolizing drugs that's imparting some disparity in outcome or anything in that avenue, we want to identify it and we want to be able to offer something to help our patient. That's still to be done. Then of course, thinking forward in how we can design some prospective interventions for our patient is a next step for us. I'm looking forward to working with Dr. Knight and working with some of our Wake colleagues on the Population Health team, who are just fantastic, to find a way forward here.

Oncology Data Advisor: Absolutely. Thank you so much for talking with us, and also for engaging in this research and helping to blaze the trail and address these disparities.

Dr. Ragon: Thanks for having me and highlighting our work.

About Dr. Ragon

Brittany Ragon, MD, is an Assistant Professor and an Adult Leukemia and Transplant Specialist at Levine Cancer Institute, Atrium Health, in Charlotte, North Carolina. She specializes in acute myeloid leukemia, myelodysplastic syndromes, bone marrow failure syndromes, and stem cell transplantation. Dr. Ragon's research focuses on early-phase clinical trials of novel therapies for hematologic malignancies, using informatics to explore genetic conditions that impact outcomes, and mitigating outcomes disparities experienced by leukemia patients.

For More Information

Ragon BK, Boselli D, Bose R, et al (2023). Neighborhood disadvantage is associated with inferior overall survival for acute myeloid leukemia patients treated with standard intensive induction. Abstract 3799. Presented at: 2023 American Society of Hematology Annual Meeting. Available at:

Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor. 

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