Many patients with acute myeloid leukemia (AML) achieve remission after induction chemotherapy, but the rates of relapse remain high [1]. The use of upfront hematopoietic stem cell transplant (HCT) increases the chances of cure in intermediate- and adverse-risk AML [2]. Apart from the effect of conditioning regimens, the graft-versus-leukemia effect offered by allogeneic HCT results in decreased cumulative incidence of relapse and superior survival outcomes in terms of disease free and overall survival [3]. Based on this evidence, the European LeukemiaNet (ELN) guidelines also recommend the use of HCT in first complete remission (CR) in patients with intermediate or adverse-risk AML [4].

Owing to the advances in hematopoietic stem and progenitor cell mobilization techniques, better supportive care, and the broader use of transplantation—including from mismatched and haploidentical donors as well as in older patients—there has been a steady global increase in the application of HCT [5], [6]. Despite the growing number of transplants, the unique operational, financial, and technical challenges of HCT contribute to healthcare disparities in eligible patients. Utilization of HCT is also marred by age, socioeconomic factors, and racial disparities [7], [8], [9], [10]. The influence of sociodemographic and clinical factors on the survival of HCT recipients has led to incorporation of various factors -such as insurance coverage, geographical distance from the HCT center, transportation options, caregiver support, ability to take leave from work, household financial dependency on the recipient's income, and caregiving responsibilities in the pre-HCT evaluation [11], [12]. These considerations are crucial in identifying potential barriers that may hinder a patient's ability to pursue, complete, or safely undergo HCT. Increasingly, these factors are being discussed within the broader context of the transplant ecosystem [12], rather than as isolated elements, making it essential to study them in today’s context. In line with these studies, we hypothesized that biological, socioeconomic and health system factors are important determinants of the use of HCT in patients undergoing treatment for AML in the US. Our study aims to provide a comprehensive analysis of trends in HCT usage among patients with AML from 2004 to 2019, aiming to quantify the most recent rates and patterns of HCT utilization and offering a more up-to-date perspective on how these factors have evolved over time. Furthermore, we also evaluate in detail, the role that sociodemographic and clinical factors play in influencing HCT access and outcomes, which has been less thoroughly explored in prior studies. An additional analysis was conducted for the year 2020 to assess disparities in HCT utilization during the COVID-19 pandemic.