Prevalence and Impact of Poverty in Pediatric Allogeneic Hematopoetic Stem Cell Transplant

Background: Despite emerging evidence of substantial financial distress in families of children with cancer, little is known about the impact of economic hardship on pediatric hematopoetic stem cell transplant (HSCT) outcomes. Poverty is known to be correlated with negative health outcomes in pediatric primary care and subspecialties; it is not known how poverty impacts HSCT outcomes.

Objective: To describe the baseline prevalence of poverty and material hardship in the pediatric HSCT population at a major referral center. To describe transplant-related work disruptions and income losses stratified by federal poverty level (FPL) in this patient population, and explore the relationship between family poverty and clinical outcomes.

Methods:  Single institution, cross-sectional survey.  Participants included 45 English-speaking, pediatric allogeneic HSCT families whose children had undergone HSCT in the prior twelve months and were alive at time of survey administration. Eighty-seven percent of families approached consented to study participation. This study was approved by the Dana-Farber Cancer Institute Institutional Review Board.

Results: Poverty prior to transplant was prevalent with 18 (40%) families reporting baseline incomes at or below 200% FPL ($44,000 for a family of four). Parental work disruptions due to HSCT were common across all income levels with 39 (87%) families reporting some disruption, and consequent income losses were substantial for all families. Families at or below 200% FPL were disproportionately impacted with 7 (39%) of the poorest families reporting transplant-associated annual income losses of >40% as compared to 2 (18%) of the wealthiest families (p=0.006). Material hardship during the post-transplant period was widespread, with 17 (38%) families reporting either food, housing, or energy insecurity. Baseline family poverty level was not associated with length of transplant admission, unplanned re-admissions, or ICU stay in the 6-month post-transplant period in univariate analysis. Poorer children, however, were more likely to experience Graft Versus Host Disease (GVHD) of any grade in the 6 month post-transplant period with eleven (61%) of those at or below 200% FPL experiencing GVHD as compared with 2 (18%) of the wealthiest (p=0.01).   

Conclusion: Baseline poverty is widely prevalent in the pediatric HSCT population, and poverty may be associated with the development of GVHD.  Material hardship during the post-transplant period—including food, housing, or energy insecurity—is widespread.  Further studies aimed at understanding how these social determinants of health contribute to HSCT outcomes may provide targetable factors to decrease transplant-associated morbidity and mortality.