Role of race and ethnicity in survival among children/young adults with relapsed ALL: a Children’s Oncology Group report

Ligon JA, Ji L, Dang A, Xu X, Rheingold SR, Bhojwani D, Devidas M, Kairalla JA, Shago M, Heerema NA, Carroll AJ, Borowitz M, Wood BL, Winick NJ, Carroll WL, Hunger SP, Raetz EA, Loh ML, Gupta S, Winestone LE. Role of race and ethnicity in survival among children/young adults with relapsed ALL: a Children’s Oncology Group report. Blood Adv. 2025 Nov 25;9(22):5738-5751. doi: 10.1182/bloodadvances.2025016670. PMID: 40815811; PMCID: PMC12661295.

Pediatric Hispanic and Black patients with newly diagnosed B-cell acute lymphoblastic leukemia (B-ALL) experience worse overall survival (OS). We hypothesized that differential outcomes by race and ethnicity following relapse may contribute to disparities. We examined 2053 patients with ALL enrolled in frontline Children’s Oncology Group trials from 1996 to 2014 who relapsed. We assessed the association of race and ethnicity, disease characteristics, and socioeconomic status with relapse survival predictors and postrelapse OS. For noninfant B-ALL, postrelapse OS (P = .002) and disease-related prognosticators such as time to relapse (P = .0002) differed by race and ethnicity. After adjusting for disease and patient characteristics, the OS association with overall race and ethnicity was attenuated, and lost statistical significance; Hispanic ethnicity specifically remained associated with worse OS (hazard ratio [HR], 1.19; 95% confidence interval [CI], 1.01-1.41). Patients from highest annual median household income ZIP codes (>$85 000, approximately the highest quartile of patients) had better 5-year OS than those from the lowest (<$50 000; HR, 0.79; 95% CI, 0.63-0.99). Non-Hispanic Black and Hispanic patients more commonly lived in lower-income ZIP codes. For T-cell ALL, race, ethnicity, and socioeconomic status were not associated with OS. Worse postrelapse outcomes among racial and ethnic minority patients are largely driven by the prevalence of adverse disease-related factors at time of relapse, with a persistent disparity observed in Hispanic patients. The greatest impact in decreasing racial and ethnic B-ALL outcome disparities may be achieved by targeting frontline treatment interventions to address increased relapse among Black and Hispanic patients, and by developing and enabling equitable access to effective relapse treatments such as novel immunotherapies.