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Xu et al. J Transl Genet Genom 2021;5:218-39 Journal of Translational
DOI: 10.20517/jtgg.2021.20
Genetics and Genomics

Review Open Access

Disparities in acute lymphoblastic leukemia risk and
survival across the lifespan in the United States of

America

1,2
1,2
1,2
Keren Xu , Qianxi Feng , Joseph L. Wiemels , Adam J. de Smith 1,2
1
Center for Genetic Epidemiology, Department of Preventive Medicine, Keck School of Medicine of the University of Southern
California, Los Angeles, CA 90033, USA.
2
Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90033, USA.
Correspondence to: Dr. Adam J. de Smith, Center for Genetic Epidemiology, Department of Preventive Medicine, Keck School of
Medicine of the University of Southern California, 1450 Biggy St., NRT-1509H, USC Norris Comprehensive Cancer Center, Los
Angeles, CA 90033, USA. E-mail: adam.desmith@med.usc.edu

How to cite this article: Xu K, Feng Q, Wiemels JL, de Smith AJ. Disparities in acute lymphoblastic leukemia risk and survival
across the lifespan in the United States of America. J Transl Genet Genom 2021;5:218-39.
https://dx.doi.org/10.20517/jtgg.2021.20

Received: 7 Apr 2021 Accepted: 3 Jun 2021 First online: 8 Jun 2021

Academic Editor: Susan L. Slager Copy Editor: Xi-Jun Chen Production Editor: Xi-Jun Chen

Abstract
Acute lymphoblastic leukemia (ALL) is the most common childhood cancer but is less frequent in adolescents and
young adults (AYAs) and is rare among older adults. The 5-year survival of ALL is above 90% in children, but
drops significantly in AYAs, and over half of ALL-related deaths occur in older adults. In addition to diagnosis age,
the race/ethnicity of patients consistently shows association with ALL incidence and outcomes. Here, we review
the racial/ethnic disparities in ALL incidence and outcomes, discuss how these vary across the age spectrum, and
examine the potential causes of these disparities. In the United States, the incidence of ALL is highest in
Hispanics/Latinos and lowest in Black individuals across all age groups. ALL incidence is rising fastest in
Hispanics/Latinos, especially in AYAs. In addition, survival is worse in Hispanic/Latino or Black ALL patients
compared to those who are non-Hispanic White. Different molecular subtypes of ALL show heterogeneities in
incidence rates and survival outcomes across age groups and race/ethnicity. Several ALL risk variants are
associated with genetic ancestry, and demonstrate different risk allele frequencies and/or effect sizes across
populations. Moreover, non-genetic factors including socioeconomic status, access to care, and environmental
exposures all likely influence the disparities in ALL risk and survival. Further studies are needed to investigate the
potential joint effects and interactions of genetic and environmental risk factors. Improving survival in
Hispanic/Latino and Black patients with ALL requires advances in precision medicine approaches, improved access

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as
long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and
indicate if changes were made.

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