Expanded alloHCT capacity in Ontario health system improved survival for older patients with AML

July 2026

Acute myeloid leukemia (AML) remains the most common acute leukemia in adults, with a median age at diagnosis of 69 years and poor long-term survival. Allogeneic hematopoietic cell transplantation (alloHCT) is a standard-of-care option for patients at higher risk of relapse. However, it has historically been offered less to older patients, largely due to concerns about treatment-related toxicity.

Despite steady growth in the use of alloHCT in North America over the last few decades, it remains underutilized in the Canadian province of Ontario, suggesting that some patients were not able to access this potentially life-saving treatment.

In 2016, the Ontario Ministry of Health initiated an expansion of transplant infrastructure to decrease waiting times and improve transplant access. These improvements included:

• Increasing inpatient bed capacity and outpatient treatment rooms
• Expanding ancillary infrastructure such as laboratory spaces, clean room environments and emergency power
• Financial investment in transplant centers

Researchers used administrative databases to understand how these investments translated into improved access and outcomes to alloHCT for patients with AML.

This was a retrospective, population-based study using Ontario administrative health data from 2010-2022 for 5,213 adults with AML. Patients had a median age at diagnosis of 67 years (interquartile range [IQR]: 57-75 years).

• 79% received chemotherapy-only treatment, while 21% received alloHCT.
• 62% received low intensity therapy, while 38% received intensive chemotherapy.

Patient outcomes were stratified by age, chemotherapy intensity and time period.

Key findings include:

• AlloHCT use increased from 12% (2010) to 25% (2022)
• Utilization rates increased across all age groups, including older adults
• 18-39: 38% to 66%
• 40-59: 20% to 54%
• 60-69: 9% to 36%
• ≥70: 0% to 5%
• Median time to transplant decreased from 6.5 months in 2010-2014 to 4.6 months after 2015 (IQR 3.4–6.0)
• Older age, comorbidity burden, rural resident and lower income were significant predictors of reduced transplant access

Researchers also assessed survival outcomes and found a survival advantage with alloHCT.

• Median overall survival (OS): 6.8 years in alloHCT vs. 1.2 years in chemo-only group (p<0.0001)
• 2 year-OS: 62% in alloHCT vs. 39% in chemo-only group

Analysis by age showed no survival benefit for alloHCT in the younger group (18-39 years), but a significant benefit in older groups.

• 40–59 years (54% vs. 64%; P = 0.006)
• 60–69 years (38% vs. 60%; P < 0.0001)
• ≥70 years (23% vs. 41%; P = 0.04)

AlloHCT independently predicted improved OS, while older age, male sex and comorbidity burden were associated with worse outcomes.  Survival gains were greatest in recent years, with alloHCT recipients in 2019–2022 experiencing a 47% reduction in mortality risk compared to earlier periods (HR 0.5), while chemotherapy-only outcomes remained unchanged. 

This study reinforces that expanding alloHCT access by growing transplant capacity can improve survival for patients with AML across age groups and chemotherapy intensities. Patients 40-69 years old experienced the strongest gains. However, access disparities continue to exist for patients who are older, have more comorbidities, live in a rural area and earn less income, even in a single payer health system. This unequal access represents a critical opportunity to ensure that patients who may benefit from alloHCT can access it.

These figures illustrate the 10-year OS of patients with AML who received alloHCT vs. chemotherapy (A), alloHCT vs. intensive chemotherapy and alloHCT vs. non-intensive chemotherapy (C).

Salter, et al., published in Blood Cancer J