Child Opportunity Index and Survival After Pediatric Hematopoietic Cell Transplantation for Acute Leukemia.

BACKGROUND: Despite advances in pediatric hematopoietic cell transplantation (HCT) for acute leukemia, many children still experience relapse and non-relapse mortality (NRM). Whether neighborhood socioeconomic context is a risk factor in pediatric HCT remains unclear. OBJECTIVE: To evaluate the association between neighborhood opportunity, measured by the Child Opportunity Index (COI 3.0) and outcomes following first allogeneic HCT for pediatric acute leukemia. STUDY DESIGN: We conducted a single-center retrospective cohort study of 147 children transplanted from 2012 to 2021. COI 3.0 is a validated composite measure of neighborhood-level resources and conditions capturing opportunities for child development. Primary analysis modeled COI as a five-level categorical exposure; exploratory analyses compared very low opportunity versus the remainder of the cohort. Outcomes included acute graft-versus-host disease (aGVHD), overall survival (OS), event-free survival (EFS), relapse, NRM, infections, and healthcare utilization. RESULTS: In prespecified analyses, five-level neighborhood opportunity was not associated with clinical outcomes. In exploratory analyses, children in very low opportunity neighborhoods (N=30) experienced inferior OS compared with the remainder of the cohort (55% vs. 76%, p=0.01), after adjustment for detectable disease pre-HCT (adjusted HR 2.47, 95% CI 1.26-4.83, p=0.01). Relapse (37% vs. 28%) and NRM (10% vs. 7%) were higher among those in very low opportunity neighborhoods but were not statistically significant. No other differences were observed. CONCLUSIONS: In this single-institution cohort, children from very low opportunity neighborhoods experienced inferior survival after HCT for acute leukemia in exploratory analyses. Neighborhood opportunity should be investigated in larger, multi-institutional cohorts as a clinical risk factor for poor outcomes.