Guideline-concordant treatment among adolescents and young adults with acute lymphoblastic leukemia

Abstract

Background: Individuals diagnosed with acute lymphoblastic leukemia (ALL) between adolescents and young adults aged 15-39 years face poor survival and unique challenges. We evaluated facility-level factors and guideline-concordant care among adolescents and young adults with ALL at National Cancer Institute Community Oncology Research Program (NCORP) practices.

Methods: We assembled a retrospective cohort of adolescents and young adults aged 15-39 years with ALL treated at participating NCORPs between 2012 and 2016. NCORPs abstracted patient data and completed facility-level questionnaires for each clinical facility (study-defined criteria). The central review committee adjudicated whether treatment was concordant with adolescent and young adult-specific National Comprehensive Cancer Network ALL guidelines (ie, pediatric-inspired therapy or clinical trial). Guideline-concordant care was described by age, facility model (adult/internal medicine, pediatric, mixed [pediatric services within a general hospital]), and average annual adolescents and young adult ALL volume. Generalized linear mixed effects models estimated the odds of guideline-concordant care.

Results: Adolescents and young adults receiving guideline-concordant care were younger (n = 196; median = 19.5 years) than those who did not (n = 31; median = 32.1 years). Guideline-concordant care was observed in many adolescents and young adults aged 22-39 years (68.8%), and nearly universal in those aged 15-21 years. In multivariable analyses, adolescents and young adults at adult/internal medicine clinical facilities had lower odds of guideline-concordant care (odds ratio = 0.02, 95% confidence interval = 0.0 to 0.18); there was no statistically significant association between annual adolescent and young ALL volume and receiving guideline-concordant care. Guideline-concordant care was observed more often in adult/internal medicine and/or mixed clinical facilities with communication between adult or pediatric counterparts, adolescents and young adult ALL clinical pathways, and/or adolescent and young adult-specific meetings.

Conclusion: Guideline-concordant care among adolescents and young adults with ALL (specifically pediatric-inspired therapy) at NCORPs is associated with facility model (adult/internal medicine) but not adolescent and young adult ALL volume. Strategies to improve guideline-concordant care could include facilitating communication and clinical pathways at adult/internal medicine clinical facilities treating adolescent and young adult ALL.

Figure 1.

Guideline-concordant treatment by age group and facility model. Figure 1 presents the rate of guideline-concordant care among adolescents and young adults by (A) age group and (B) facility model. Each panel presents a series of bars that represent Philadelphia-chromosome negative (Ph-) and positive (Ph+) B-cell acute lymphoblastic leukemia (ALL), and T-cell ALL. All patients who received guideline-concordant care received a guideline-concordant regimen (Ph- and T-ALL = pediatric-inspired therapy; Ph+ = multi-agent plus tyrosine kinase inhibitor). The total number of each subgroup is represented on the x-axis. Abbreviations: IM = internal medicine; pts = patients.

Figure 2.

Guideline-concordant treatment by annual volume of adolescent and young adult acute lymphoblastic leukemia (ALL). Figure 2 presents the rate of guideline-concordant care among adolescents and young adults by (A) annual volume of adolescent and young adult ALL and (B) facility model and volume. Of note, not all clinical facilities responded to the question regarding average annual ALL volume. Findings represent the proportion of patients with a known clinical facility volume. The total number of each subgroup is represented on the x-axis. Abbreviations: IM = internal medicine; pts = patients.

Figure 3.

Adolescent and young adult–specific process characteristics and guideline-concordant therapy by facility model and annual adolescent and young adult volume. Figure 3 presents the rate of guideline-concordant care among adolescents and young adults by the presence of discrete process characteristics and (A) facility model and (B) annual volume of adolescent and young adult acute lymphoblastic leukemia. The total number of each subgroup is represented on the x-axis. Abbreviations: ALL = acute lymphoblastic leukemia; AYA = adolescent and young adult; IM = internal medicine; N/A = not applicable.