Inequalities in treatment and survival of acute myeloid leukaemia (AML) and diffuse-large B cell lymphoma (DLBCL) in Japan and England: Implications for cancer policy

Title of PhD project

Inequalities in treatment and survival of acute myeloid leukaemia (AML) and diffuse-large B cell lymphoma (DLBCL) in Japan and England: Implications for cancer policy

Supervisory team


Lead: Prof Bernard Rachet (Faculty of Epidemiology and Population Health,

Dr Mari Kajiwara Saito (

Nagasaki University

Prof Yasushi Miyazaki (Department of Haematology, Nagasaki University Hospital, The director of Atomic Bomb Disease Institute.                                                                                

Brief description of project


To explore the key factors to explain inequalities in the treatment and survival of AML and DLBCL in Nagasaki, Japan, and contrast the situation with England.


Survival of DLBCL improved over the last five decades due to well-established treatment, while that of AML started to improve only recently with a better understanding of molecular pathophysiology. However, for both diseases, inequalities in survival by age, sex, socioeconomic status or geographical area have been reported in countries having universal health coverage.

Treatment for DLBCL is usually started with R-CHOP and is highly curative for most patients (curative for 60–70% of patients with advanced disease). Treatment of AML requires more intensive care than DLBCL, and patients have high risks of dying from both disease-related and treatment-related complications. Some AML patients may require a haematopoietic stem cell transplant (HSCT).

In Japan, patients with DLBCL are usually treated in designated cancer care hospitals (DCCHs). DCCHs are allocated at least one per every secondary medical area (SMA) nationwide so that patients can receive and complete care within their SMA of residence. For HSCT, the care is more centralised; different operations from DCCHs have been established by broader area (eight blocks nationwide), building a strong network between areas to aim for seamless care coordination. Because HSCT needs an urgent timeline, the HSCT programme facilitates opportunities for regional doctors within the network to consult specialised haematologists in a designated HSCT hospital and a speedy referral system to minimise the time to HSCT. They also collaborate with the Donor Bank. However, survival inequalities may exist between non-designated HSCT hospitals and designated HSCT hospitals or hospitals within the network. The non-designated hospitals may continue providing chemotherapy, that is, suboptimal care, even if the patient is a good candidate for receiving HSCT. Also, HSCT protocol may not be standardised by hospitals (e.g., some inexperienced non-designated HSCT hospitals may seek relative donors only because they are not collaborating with the Donor Bank which provides non-relative donors).

In this project, we aim to see whether inequalities in optimal care and in survival for AML and DLBCL by geographical area (and socio-economic level if possible) exist in Nagasaki Prefecture and explore which factors can explain the inequalities.


  • To examine whether such inequalities exist by geographical area (between urban and remote island areas, and according to travel time to closest DCCH) for patients with AML and DLBCL in Nagasaki Prefecture.
  • Using causal mediation analysis, examine whether survival inequalities can be explained by patient factors (age, sex, comorbidities), disease factors or geographical areas, and contrast the situations between AML and DLBCL.
  • To interpret and explain the results considering the organisation and coordination of care for AML and DLBCL in Nagasaki Prefecture.
  • To contrast the situation in Japan with that in England and identify policy implications to improve care (e.g., what level of centralisation or decentralisation is needed for AML or DLBCL in each country, combined with which level and type of care coordination?)

Potential sources of data

  • Cancer registry data in Nagasaki Prefecture
  • Clinical information will be obtained through administrative claims data (Diagnosis Procedure Combination: DPC data)


Berger E, Delpierre C, Despas F, et al. Are social inequalities in acute myeloid leukemia survival explained by differences in treatment utilization? Results from a French longitudinal observational study among older patients. BMC Cancer 2019; 19(1): 883.

John MJ, Kuriakose P, Smith M, Roman E, Tauro S. The long shadow of socioeconomic deprivation over the modern management of acute myeloid leukemia: time to unravel the challenges. Blood Cancer J 2021; 11(8): 141.

Smith MJ, Rachet B, Luque Fernandez MA. Mediating effects of diagnostic route on the comorbidity gap in survival of patients with Diffuse Large B-Cell or Follicular Lymphoma in England. Cancers 2022; 14.

Nakata K, Williams R, Kinoshita Y, et al. Comparative analysis of the clinical characteristics and outcomes of patients with Wilms tumor in the United Kingdom and Japan. Pediatr Blood Cancer 2021; 68(10): e29143.

The role of LSHTM and NU in this collaborative project

The ICON group in the LSHTM provides academic training in quantitative analytic methods, co-supervision and support for contrasting findings with England.

The NU provides data from Japan (Nagasaki), understanding of the data and of cancer patient journey, as well as co-supervision of the project.

Particular prior educational requirements for a student undertaking this project

  • A master degree related to epidemiology, public health or other courses relevant to a subject of the project.
  • An upper second-class honours degree from a university in the UK, or an equivalent standard of an overseas qualification related to a subject of the project.

Skills we expect a student to develop/acquire whilst pursuing this project

The student is expected to develop skills on extended epidemiology related to survival analysis and causal mediation analysis. The student is also expected to develop academic skills through transferable skills courses provided from the LSHTM.