Disparities in treatment timing and access to care in chronic lymphoytic leukemia Free

Background:

Chronic lymphocytic leukemia (CLL) is the most common adult leukemia in Western countries. Advances in CLL treatment over the past decade have shifted care from chemoimmunotherapy towards targeted oral therapies, which made this a more manageable disease for many patients. Current guidelines from the NCCN recommend initiating treatment only when patients develop active disease, based on symptomatic lymphadenopathy, progressive cytopenia, or constitutional symptoms. However, despite these advances in treatment, there are still disparities in treatment timing and access, especially among racial and ethnic minorities, those living in rural or underserved geographic areas, and socioeconomically disadvantaged patients. The American Society of Hematology (ASH) identified achieving equity in hematologic care as part of its mission. In 2021, ASH called for increased research and action addressing disparities in cancer care delivery, particularly patients from marginalized communities. This scoping review aims to summarize existing literature in CLL treatment initiation and access, with a focus on racial, geographic, and socioeconomic factors.

Methods:

Our scoping review of original research articles published between 2015 and 2025 examined treatment timing and access to care in adult patients with CLL. This review followed PRISMA guidelines, with database searches including PubMed, EMBASE, COCHRANE and Medline. Studies were eligible if they addressed the following: chronic lymphocytic leukemia, time to treatment, treatment delay, treatment initiation, time to first treatment, watch and wait, watchful waiting, health disparity, racial disparity, ethnic disparity, socioeconomic factor, socioeconomic status, income, poverty, insurance status, healthcare access, access to care, rural health, rural population, urban population, geographic variation, minority group, race, ethnicity, or healthcare disparity. Due to variability in study aims and outcome measure, data was synthesized narratively. Risk of bias was evaluated using ROBINS-I.

Results:

Five U.S.based studies comprising 102,994 adult patients with CLL met inclusion criteria. Four were large retrospective cohort studies using national datasets like SEER-Medicare, while one study used EMR data from a tertiary academic center. All studies included data from multiple states or national samples. Most were retrospective cohort studies with predominantly non-Hispanic White populations, Black and Hispanic patients were underrepresented (<10% of cohorts). Black patients were often diagnosed at a younger age and presented with more high-risk features such as unmutated IGHV and del(11q) compared to white patients. Treatment patterns differed; one study found higher rates of BTK inhibitor use among Black patients and more frequent first-line BTK therapy, with longer treatment durations. Others reported no significant racial differences in time to treatment or survival, suggesting similar outcomes when access is equitable. A recent study using data with novel oral agents found no survival disparities by race. However, geographic and socioeconomic factors influenced care. One found that living in counties with high social vulnerability related to minority status or language was associated with delayed treatment initiation. Similarly, living in areas with a median household income under $75,000 was also linked to delayed treatment initiation. Another reported that site of care (academic vs. community) was associated with overall survival from the start of first line therapy, though this was not linked to race or ethnicity. Overall, while disparities seem less pronounced with oral agents, persistent socioeconomic and geographic disparities may continue to affect timely treatment and outcomes.

Discussion:

This scoping review summarizes how disparities in treatment initiation and access for CLL patients are intersectional. Race, geographic location, and socioeconomic status all influence when and how patients are treated. Our review contributes to the evidence of these disparities and identifies targets for future intervention. As the care of CLL evolves, addressing and closing these gaps is essential to improve outcomes for all CLL patients.