Leukemia, a group of chronic malignant neoplastic diseases characterized by the uncontrolled proliferation of abnormal white blood cells, exerts profound and multifaceted impacts on patients-disrupting physical health, triggering psychological distress, and imposing heavy economic burdens (1, 2). As a major global public health challenge (3), its burden exhibits striking geographic heterogeneity, particularly in low- and middle-income settings where healthcare access remains constrained (4). In China, while the overall leukemia incidence is categorized as intermediate compared to global benchmarks (5), the disease’s distribution and impact in poverty-alleviated regions have long been underappreciated. This oversight is critical, as impoverished populations in these areas face a unique conundrum: limited access to primary care amplifies leukemia risk (4), and the disease itself acts as a potent driver of both persistent poverty and poverty recurrence-a “disease-poverty trap” that undermines the sustainability of China’s anti-poverty achievements.

China’s “Precision Poverty Reduction” strategy, launched in the late 2010s, marked a pivotal step in addressing health-related poverty. By reducing Out-Of-Pocket (OOP) medical expenses and curbing catastrophic healthcare costs, the policy significantly improved healthcare accessibility in impoverished counties (6). However, since China officially declared the elimination of absolute poverty in 2020, emerging evidence suggests that health-related financial burdens persist. Many families in poverty-alleviated regions still face the threat of returning to poverty due to high leukemia treatment costs. This highlights a critical gap between policy implementation and sustained health equity. Compounding this challenge, the epidemiological characteristics of leukemia in these newly poverty-free areas-including trends in incidence, mortality, and their spatiotemporal dynamics-have not been systematically quantified. Prior studies on Chinese leukemia burden have either focused on national or provincial scales (2, 5) or pre-poverty alleviation periods (4), leaving a void in understanding how the disease’s burden has evolved after the lifting of absolute poverty. Similarly, research on leukemia’s economic impact in these regions has been largely unidimensional, often focusing solely on OOP costs without integrating relative financial toxicity metrics (e.g., OOP ratios relative to household health expenditure), a limitation that obscures the true extent of economic vulnerability.

To fill these gaps, we conducted a multidimensional analysis of leukemia in 832 poverty-alleviated counties across China’s four major economic regions (Northeast, Central, East, and West) from 2019 to 2024. Leveraging population-based data from China’s Health Poverty Alleviation Big Data Platform-one of the largest datasets on post-poverty health outcomes to date-we analyzed 97,472 newly diagnosed leukemia cases. Our study aimed to address three core research questions: (1) How have leukemia incidence and mortality rates changed longitudinally in post-poverty counties, and do these trends differ by age, sex, or region? (2) What are the spatiotemporal dynamics of leukemia burden-including spatial clustering and regional shifts-across the study period? (3) How is the economic burden of leukemia (measured by both absolute OOP costs and relative OOP ratios) distributed across regions, and what factors drive these disparities?

This study represents the first epidemiological spatio-temporal analysis of leukemia among a population of 832 poverty-eradication counties across four major economic regions of China from 2019 to 2024. It holds significant importance for enhancing the targeting of leukemia prevention and control efforts, as well as for improving the effectiveness of preventing a resurgence of poverty attributable to leukemia.

The incidence of leukemia is significantly higher among the impoverished population in the eastern and northeastern regions compared to the western regions, particularly during the period from 2019 to 2021. This disparity may be attributed to various factors, including environmental conditions, lifestyle choices, and inadequate access to healthcare. Industrial pollution is a significant contributor to the elevated incidence of leukemia in the eastern region (2, 5), where individuals are more frequently exposed to harmful substances such as benzene. This exposure damages bone marrow and leads to chromosomal abnormalities, thereby increasing the likelihood of individuals developing leukemia (8–10). Secondly, the accelerated urbanization in the eastern region has resulted in significant lifestyle changes, with dietary patterns marked by high intake of fats, sugars, and salts recognized as a known risk factor for various types of leukemia, particularly chronic lymphocytic leukemia and granulocytic leukemia (11–13). Additionally, inadequate healthcare infrastructure, limited access to healthcare services (14), and low awareness of leukemia symptoms (15) may contribute to delayed diagnosis and increased morbidity. To address this issue, several measures have been implemented in the eastern region, including enhancing public health awareness and knowledge related to leukemia, promoting healthy lifestyles, strengthening environmental protection to mitigate chemical and environmental pollution (16, 17), screening and monitoring at-risk groups to identify and address potential issues, and establishing health policies and interventions tailored to the specific needs of the population in eastern China. The specific needs of the population in eastern China are addressed in reference (2). Improved access to healthcare has enabled more individuals to receive timely diagnoses and treatments (18). Furthermore, advancements in medical testing and diagnostic technologies have greatly enhanced the capacity to identify leukemia (5). As the economy progresses, the integration of advanced medical technologies and treatment options, such as targeted therapies and hematopoietic stem cell transplants, has markedly improved patient survival rates and prognoses (2).

Crucially, this observed hotspot expansion in western China post-2022, as identified by our Getis-Ord Gi analysis (Figure 5), stands in apparent contrast to the significant declines in national leukemia incidence and mortality reported herein (Table 1). This phenomenon presents the paradox of ‘high resource allocation leading to an apparent high disease burden’ at the local level and warrants specific consideration in relation to Health Poverty Alleviation (HPA) policy impacts. The post-2022 expansion of hotspots (Figure 5) reflects the progressive rollout of HPA interventions reaching deeper into Western regions, unmasking the pre-existing, but previously undiagnosed, burden of leukemia. This increased detection directly results from higher resource investment aimed at improving health equity. Thus, the seemingly paradoxical emergence of ‘high burden’ (hotspots) in the West following ‘high resource’ (HPA) investment is not indicative of a failure of the policies or an actual worsening of leukemia burden, but rather a testament to their success in improving case ascertainment and bringing previously hidden cases into the healthcare system. This phenomenon aligns with the identified peak in 2020 being attributable to uncovered backlogged cases (discussed earlier), but demonstrates its spatio-temporally evolving nature, shifting focus to disadvantaged western regions as HPA interventions deepened after 2020. Before 2022, the basic medical facilities in western China were relatively weak (19), with a lower number of health technicians per thousand population compared to the eastern region (20). This situation severely impacted the quality and accessibility of medical services. Consequently, leukemia’s were more likely to develop (21) and were often diagnosed at later stages, leading to higher morbidity and mortality rates (22) between 2019 and 2021 (23). However, following economic development and the poverty alleviation of impoverished counties (24), significant improvements have been made. With advancements in diagnostic capabilities and timeliness (25), the detection rate of leukemia has steadily increased in poverty-stricken regions of Western China (26). Getis-Ord Gi* analysis revealed significant hotspot expansion in western China post-2022 (Figure 5), contrasting with the prior northeast-central clustering pattern.

The distribution of the economic burden of leukemia is markedly uneven, with the eastern and central regions facing a greater economic burden than the poorer western regions, despite having better access to healthcare resources. With the OOP ratio median (39.7%) nearing the WHO catastrophic threshold (40%) (27), eastern China exhibits critical vulnerability to financial toxicity despite higher economic development (Figure 6). This suggests systemic inefficiencies in public coverage for leukemia care, demanding urgent formulary expansion to novel therapies. This high economic burden in the eastern and central regions may stem from a cycle characterized by “high healthcare resources - high treatment demand.” The advanced medical facilities and specialists available in these regions provide better treatment options and outcomes for leukemia patients, who often have elevated expectations regarding their treatment (28). However, the depth of health insurance coverage is frequently inadequate to fully cover the costs associated with leukemia-related treatments. Consequently, the involvement of insurance companies can lead to catastrophic medical expenditures, which significantly impact impoverished families (29).

Quality healthcare resources tend to attract more complex cases, such as those requiring hematopoietic stem cell transplantation. Conversely, inadequate coverage in health insurance catalogs compels patients to pay OOP for innovative drugs (30). This significant financial burden can heighten stress and anxiety for both patients and their families, complicating the disease management process (5, 31) and potentially leading families to abandon treatment, which can have severe consequences (32). In the western region, characterized by poorer economic conditions and medical standards (19, 33, 34), patients generally have lower treatment expectations and rely more heavily on local medical resources. This reliance often results in poorer treatment outcomes and higher mortality rates (35, 36) despite the relatively lower financial burden (37).

To address the significant financial burden in the east-central region, a pilot leukemia-specific healthcare voucher could be implemented to cover the OOP expenses associated with new targeted therapies. Additionally, expanding the scope of healthcare insurance and promoting the integration of commercial insurance with basic healthcare insurance would provide health-related financial risk protection for the impoverished, thereby reducing the likelihood of further poverty due to catastrophic healthcare expenditures (38, 39). Furthermore, the reimbursement rate for leukemia treatments should be increased, and a cross-provincial medical collaboration network should be established to lower the costs associated with inter-regional patient mobility. To tackle the issue of inadequate healthcare resources in the western region, the government should prioritize investments in enhancing healthcare facilities and services, elevating the level of medical assistance in impoverished counties, and ensuring that all individuals have access to basic medical insurance, major disease insurance, and medical assistance (40, 41). Lastly, efforts to improve public health literacy should be intensified to enhance overall health outcomes and decrease the incidence of disease-related poverty (42, 43).

Transcending the provincial-scale spatial analyses dominating leukemia burden research and unidimensional economic evaluations, this study introduces three integrated innovations: First, a granular spatiotemporal framework analyzes county-level dynamics (n = 832 counties) through terrain-adjusted spatial autocorrelation (Global Moran’s I; Getis-Ord Gi*) coupled with Joinpoint regression (BIC-optimized inflection detection). Second, we establish a dual-burden quantification system, capturing both absolute OOP costs and relative financial toxicity (OOP ratios), revealing significant inter-regional disparities. Crucially, we reframe 2022–2024 high-burden clusters not as policy failures but as evidence of diagnostic catch-up success, where spatial case ascertainment bias serves as an equity-sensitive metric for healthcare modernization impact.

Although this study systematically assessed the spatial distribution characteristics of leukemia incidence and its economic burden, the following limitations remain: 1. Data coverage bias: the data from the poverty alleviation platform may miss unregistered poor cases, especially in remote areas with poor transportation, which may lead to underestimation of incidence and distortion of spatial patterns. Follow-up studies need to validate patient coverage by combining data from multiple sources 2. Missing indirect costs: The economic analysis did not include indirect costs such as missed work and companionship, which may weaken the comprehensive assessment of the poverty-causing effects of the disease 3. Environmental and socioeconomic covariates were not fully captured and could influence spatial disparities. 4. Incomplete longitudinal socioeconomic indicators (832 counties, 2019–2024), absent age-stratified incidence matrices, and missing non-demographic covariates precluded three advanced analyses: SII/RII quantification of contextual disparities, APC modeling of cohort effects, and decomposition of population/non-population drivers. These gaps restrict cross-validation with studies using such causal inference techniques. Future work requires high-granularity socioeconomic panels, demographically disaggregated registries, and geospatial covariate libraries.