Disparities in Allo-HCT Use for AML Persist Despite Advances

Disparities in access to stem cell transplantation among people with acute myeloid leukemia (AML) appear to be persisting—and in some cases widening—even as the pool of available donors has increased.

Those are the key findings of a new report in Transplantation and Cellular Therapy that examined data from the US National Cancer Database.¹

Allogeneic hematopoietic stem cell transplantation (allo-HCT) is the only curative therapy for many patients with AML, noted corresponding author Kimberly J. Johnson, PhD, of the Washington University School of Medicine in St. Louis, and colleagues.

Yet, because of the donor-dependent nature of allo-HCT, there has long been a gap between the number of patients who are eligible for the procedure and the number of patients who actually receive it.

Johnson and colleagues said the disparity between eligibility and donor availability has long been particularly pronounced among Black patients. A 2019 analysis of patients who sought care at the Memorial Sloan Kettering Cancer Center found that just 18% of Black patients were able to receive a transplant from an 8/8 human leukocyte antigen (HLA)-allele matched unrelated donor. That was the lowest percentage of any racial or ethnic group studied.² Johnson and colleagues said such disparities were believed to be tied to a lack of suitable matched donors among Black patients.

“However, in the past decade, there has been a substantial increase in alternative donor (e.g., haploidentical, mismatched unrelated, and umbilical cord blood) utilization such that nearly all patients now have a suitable donor for transplantation,” they wrote.³ In theory, those innovations should expand the donor pool and significantly drive down disparities.

Johnson and colleagues therefore decided to analyze data from the National Cancer Database to see if the gaps between eligibility and access had shifted over time as the use of alternative donors began to increase. The authors pulled data on patients diagnosed with AML between the years 2004 and 2019, finding a total of 85,787 patients. Next, they looked at factors such as demographics, socioeconomic status, and healthcare access to see whether such factors were related to the likelihood that a patient received allo-HCT as their first course of therapy.

The investigators found that certain groups—non-Hispanic Black patients, those with Medicare, people in ZIP codes with lower education and income levels, and patients referred from community or integrated network cancer programs—were consistently less likely to receive first-course allo-HCT throughout the study period.

And while investigators had hoped the expanding set of transplantation options might have helped narrow disparities, the data suggested otherwise.

The trends, represented as annual absolute change (AAC), showed that compared with non-Hispanic White patients, the AAC in first-course allo-HCT rates was –0.18% (95% CI, –0.33 to –0.03%) for non-Hispanic Black patients. The AACs in allo-HCT rates were –0.53% (95% CI, –0.72% to –0.35%) for people on Medicaid and –0.94% (95% CI, –1.03% to –0.86%) for those with Medicare, compared to people with private insurance. The AACs in allo-HCT rates were –0.40% (95% CI, –0.49% to –0.31%) for patients from community cancer centers and –0.06% (95% CI, –0.17% to 0.06%) for patients of integrated network cancer programs, compared to people seeking care at academic or research institutions.

In short, the data indicate “a lower rate of increase in allo-HCT utilization and widening disparities” in allo-HCT access.

The authors explained additional studies will be required to understand why this is happening. However, they said it may come down to the financial burden associated with the therapy, which includes substantial indirect costs, including transportation and long-term caregiving support.

“Therefore, advantaged individuals with higher SES (socioeconomic status) may have benefited more from increased donor availability, whereas disadvantaged populations continue to face barriers that prevent them from fully benefiting from this advancement,” they wrote.

Johnson and colleagues said other potential factors include insurance acceptance issues and low rates of first complete remission prior to allo-HCT.

They concluded that these data suggest there is a “pressing need for targeted policy interventions” that address the structural barriers to equitable access to this potentially curative therapy.

References

1. Kang LC, Fiala MA, Johnson KJ. Disparities in allogeneic hematopoietic stem cell transplantation among acute myeloid leukemia patients. Transplant Cell Ther. Published online January 15, 2026. doi:10.1016/j.jtct.2026.01.019
2. Barker JN, Boughan K, Dahi PB, et al. Racial disparities in access to HLA-matched unrelated donor transplants: a prospective 1312-patient analysis. Blood Adv. 2019;3(7):939-944. doi:10.1182/bloodadvances.2018028662
3. Hong S, Majhail NS. Increasing access to allotransplants in the United States: the impact of race, geography, and socioeconomics. Hematology Am Soc Hematol Educ Program. 2021;2021(1):275-280. doi:10.1182/hematology.2021000259