Sawalha Examines the Impact of Socioeconomic Factors on the Use of Autologous Stem Cell Transplant in MCL

In an interview with CancerNetwork, Yazeed Sawalha, MD, discussed how socioeconomic factors can affect use of autologous stem cell transplant in multiple myeloma and lead to disparities.

Socioeconomic factors play an important role in determining which patients are most likely to undergo treatment with autologous stem cell transplant (ASCT), according to Yazeed Sawalha, MD, who explained that the accompanying disparities in care highlight a greater unmet need within the health care system.

According to findings from a study published in Leukemia and Lymphoma that featured a population of patients (n = 10,290) with newly diagnosed mantle cell lymphoma (MCL) who were previously treated with chemotherapy, 17% of those received treatment with ASCT. Patients who did receive ASCT tended to be younger with a lower comorbidity score, have private insurance, possess higher income and education, and were typically treated at an academic institution. Investigators found that factors such as age, comorbidity index, insurance type, transition of care, facility type, facility distance, and diagnosis year were predictive of ASCT administration. Although female gender, diagnosis in 2009 or later, private insurance, higher income, and education were associated with superior survival, factors such as Black race and higher comorbidities were predictive of interior survival.

“I hope that our study reinforces the importance of socioeconomic disparities on access to health care, and [on] clinical outcomes overall,” Sawalha explained. These become more important as our treatments continue to evolve. It would be really unfortunate if our treatments continued to get better and better, but a significant percentage of patients [couldn’t] access these good treatments because of socioeconomic factors. I hope that researchers, physicians, and health care providers along with patient advocate societies and communities continue to work together to find solutions to this very important problem.”

In an interview with CancerNetwork®, Sawalha, a hematologist at the Ohio State University Comprehensive Cancer Center–The James, highlighted the role these factors play in the receipt of care and how the oncology community may work to close the gap in disparities.

Explain the rationale for examining the impact of socioeconomic factors on the use of up-front autologous stem cell transplantation in patients with MCL?

The use autologous stem cell transplant in MCL is very controversial. Most of the studies that we have on this topic have focused on biological patient- and disease-related factors that can impact outcomes with transplants and whether patients should or should not undergo autologous stem cell transplant in MCL. We wanted to look at this topic from a different angle that’s often overlooked. We wanted to see if demographics and certain socioeconomic factors can influence the use of autologous stem cell transplant in patients with MCL. We thought about this topic because autologous stem cell transplant is a very intensive procedure [that is] highly specialized, usually [being performed] at academic institutions and large cancer centers. [Due to this, administration of ASCT] prone to socioeconomic disparities. That’s why we did [this] research.

How did socioeconomic factors play into the use of ASCT in patients with MCL?

[In addition to] looking at the impact of demographics and socioeconomic factors on the use of autologous stem cell transplant, [we] also [examined] clinical outcomes, specifically overall survival. We found that after adjusting for other factors, the type of insurance—and specifically having private insurance rather than Medicare—receiving treatment at an academic or research facility, and certain geographical locations are associated with higher chances of undergoing autologous stem cell transplantation. In terms of clinical outcomes and survival, we found that the type of insurance was also important here. In addition, higher education and income levels were also associated with superior survival, whereas Black race was associated with inferior survival.

Were there any other findings from this research that stood out to you?

We found that, overall, only a minority of patients with MCL actually underwent stem cell transplants—just 17%. Now, this might not be surprising to a lot of people because the median age of [patients with] mantle cell lymphoma is usually in the mid to late 60s, and many patients [are] ineligible for transplant just based on age and comorbidities. But even when we looked at younger patients—patients younger than the age of 60—less than one-third of them underwent autologous stem cell transplant. I thought that was an interesting finding. I think socioeconomic factors can possibly influence that. But I think patients’ and physicians’ preferences probably play an important role here, even though we couldn’t specifically address that in our study.

[Although] looking at outcomes wasn’t really the primary end point of our study, we found that younger patients, whether they get or don’t get transplant, had good outcomes. The median OS without transplant was 10 years and with transplant, [OS] was not reached. It just highlights or validates some of the results that we see in clinical trials, even though this is a population-based study. That was good to see too.

How do you foresee this research being used to improve care for these patient populations?

Our study highlights the importance of this issue—the impact of socioeconomic disparities on access to health care and clinical outcomes on survival. [It’s] very important to keep in mind as our treatments evolve and continue to get more complicated and sophisticated. For example, in MCL, CAR T cells are approved in the relapsed setting; that’s a very intensive procedure, highly specialized and very expensive. It has impressive results, and [is] efficacious. With time, it might be introduced to earlier lines of treatment so more patients might need it in the future. It’s probably going to be prone to the impact of socioeconomic disparities because of the nature of this procedure. Again, as our treatments continue to evolve [and] this topic becomes even more important, we have to address it.

How are we going to fix it? That’s obviously and important question. As physicians and researchers, there are things we can do. We can continue to highlight the importance of these factors on outcomes and access to health care. But I think overall, this is a bigger problem—[one] that’s embedded in the health care system here. We need to find a way to implement changes in the health system overall so that [we] will have opportunities for health equities and access to high quality care for our patients.

Where do you think future research efforts need to be focused?

[Although] we don’t have any plans [for future] right now based on these results, I hope that we continue to work on these important factors. This is something we also have to keep in mind when we design and conduct our clinical trials because clinical [research] can sometimes be an opportunity for patients to get treatments that otherwise might be limited as a standard of care for them. It’s important for us as researchers to keep that in mind when we design our clinical trials to make it them easier and more feasible for patients who might have socioeconomic issues.


Sawalha Y, Radivoyevitch T, Jia X, et al. The impact of socioeconomic disparities on the use of upfront autologous stem cell transplantation for mantle cell lymphoma. Leukemia & Lymphoma. Published online September 15, 2021. doi:10.1080/10428194.2021.1978085