Are There Disparities in Transplant-Related Morbidity and Mortality after Hematopoietic Stem Cell Transplant: An Institution-Based Analysis of Autologous and Allogeneic Transplant Recipients

Background: Previous national data demonstrate racial/ethnic survival disparities among hematopoietic stem cell transplant recipients. It is unclear, however, if these disparities persist in large academic settings. Therefore, we sought to investigate racial/ethnic transplant-related mortality and morbidity disparities after autologous and allogeneic transplant in our single-institution major transplant center, adjusting for the influence of patient factors, clinical factors, insurance type, and neighborhood socioeconomic status.

Methods: We conducted a retrospective chart review of all patients who received a hematopoietic stem cell transplant (autologous and allogeneic) at Stanford University during the years of 1998-2012. Kaplan Meier method predicted survival by race/ethnicity stratified by transplant type. Cox proportional hazard models estimated mortality and transplant-related morbidity (graft-versus host disease for allogeneic transplant recipients) adjusted by demographic (age, gender, race/ethnicity), clinical (diagnosis, year of transplant, treatment regimen), and socioeconomic (insurance, neighborhood socioeconomic status) factors.

Results: There were a total of 3,407 patients included in the analysis who received a hematopoietic stem cell transplant during the years of study. Unadjusted Kaplan Meier Curves showed a statistically significant improved survival for Hispanics and Asian/Pacific Islander (API) patients compared with NWH allogeneic transplant recipients (p = 0.01), however, there were no differences in survival for allogeneic transplant recipients by race/ethnicity (p=0.77). Cox proportional hazard models, among autologous transplant recipients, after adjustment for demographic, clinical, and socioeconomic status factors, demonstrated an increased mortality for API patients compared with non-Hispanic white (NHW) patients (HR 1.25 95% CI (1.01-1.57). Non-Hispanic black (NHB) had an equivalent mortality and Hispanics had a non-statistically significant mortality compared with NHW populations (HR 0.97 95% CI (0.69-1.35); HR 0.82 95% CI (0.61-1.10), respectively). Among allogeneic transplant recipients, we found no mortality disparities by race/ethnicity in fully adjusted models. However, we found transplant-related morbidity disparities with an increased odds of graft-versus-host disease among API recipients compared with NHW recipients. (OR 1.57; 95% CI (1.06-2.31)).

Conclusions: After adjustment for individual, clinical, socioeconomic and insurance status factors, we found increased mortality after autologous transplant and a higher odds of treatment-related morbidity after allogeneic transplant among API patients compared with other racial/ethnic groups. The worse outcomes among these groups despite equal access to post-transplant related care in our institution requires further investigation.