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Graboyes EM, Garrett-Mayer E, Sharma AK, Lentsch EJ, Day TA. Adherence to National Comprehensive Cancer Network guidelines for time to initiation of postoperative radiation therapy for patients with head and neck cancer. Cancer 2017; 123:2651-2660. [DOI: 10.1002/cncr.30651] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 01/29/2017] [Accepted: 02/01/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Evan M. Graboyes
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - Elizabeth Garrett-Mayer
- Department of Public Health Sciences; Division of Biostatistics and Bioinformatics, Medical University of South Carolina; Charleston South Carolina
| | - Anand K. Sharma
- Department of Radiation Oncology; Medical University of South Carolina; Charleston South Carolina
| | - Eric J. Lentsch
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - Terry A. Day
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
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52
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Therapy and outcomes of primary central nervous system lymphoma in the United States: analysis of the National Cancer Database. Blood Adv 2016; 1:112-121. [PMID: 29296804 DOI: 10.1182/bloodadvances.2016000927] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 10/21/2016] [Indexed: 11/20/2022] Open
Abstract
Although the role of radiation therapy and chemotherapy in primary central nervous system lymphoma (PCNSL) has evolved considerably over the past decade, the application of treatment modalities in the community has not been evaluated. We analyzed the use of chemotherapy, radiation therapy, and associated overall survival, among 9165 HIV-negative PCSNL cases reported to the US National Cancer Database in 2004-2013. During this time, the proportion of patients receiving chemotherapy significantly increased from 65.6% to 78.8% (P for trend <.0001), whereas the proportion receiving radiation therapy decreased from 37.6% to 18.8% (P < .0001). Adjusting for the varying distribution of clinical and sociodemographic characteristics by type of treating facility, the risk of not receiving chemotherapy was significantly lower in academic/research cancer programs compared with community programs (adjusted relative risk, 0.69; 95% confidence interval [CI], 0.62-0.76; P < .0001). Furthermore, omission of chemotherapy was associated with increasing age, comorbidities, black race, and indicators of poor socioeconomic status. Overall survival at 3 years was 37.7% (95% CI, 36.6-38.8) and ranged from 14.1% for patients treated with radiation therapy alone to 51.8% for those who received multiagent chemotherapy. There was evidence of improved survival over time (P for trend =.0002). The disparities in application of chemotherapy for PCNSL underscore the need to provide access to expert management for this rare disease and improve safe delivery of systemic treatment in the community setting, where most older patients receive their care.
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Alonso-Álvarez S, Vidriales MB, Caballero MD, Blanco O, Puig N, Martin A, Peñarrubia MJ, Zato E, Galende J, Bárez A, Alcoceba M, Orfão A, González M, García-Sanz R. The number of tumor infiltrating T-cell subsets in lymph nodes from patients with Hodgkin lymphoma is associated with the outcome after first line ABVD therapy. Leuk Lymphoma 2016; 58:1144-1152. [DOI: 10.1080/10428194.2016.1239263] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Sara Alonso-Álvarez
- IBMCC (USAL-CSIC), Hospital Universitario de Salamanca-IBSAL, Salamanca, Spain
| | | | | | - Oscar Blanco
- IBMCC (USAL-CSIC), Hospital Universitario de Salamanca-IBSAL, Salamanca, Spain
| | - Noemí Puig
- IBMCC (USAL-CSIC), Hospital Universitario de Salamanca-IBSAL, Salamanca, Spain
| | - Alejandro Martin
- IBMCC (USAL-CSIC), Hospital Universitario de Salamanca-IBSAL, Salamanca, Spain
| | | | - Esther Zato
- Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | | | - Miguel Alcoceba
- IBMCC (USAL-CSIC), Hospital Universitario de Salamanca-IBSAL, Salamanca, Spain
| | - Alberto Orfão
- IBMCC (USAL-CSIC), Hospital Universitario de Salamanca-IBSAL, Salamanca, Spain
| | - Marcos González
- IBMCC (USAL-CSIC), Hospital Universitario de Salamanca-IBSAL, Salamanca, Spain
| | - Ramón García-Sanz
- IBMCC (USAL-CSIC), Hospital Universitario de Salamanca-IBSAL, Salamanca, Spain
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54
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Lamy S, Bettiol C, Grosclaude P, Compaci G, Albertus G, Récher C, Nogaro JC, Despas F, Laurent G, Delpierre C. The care center influences the management of lymphoma patients in a universal health care system: an observational cohort study. BMC Health Serv Res 2016; 16:336. [PMID: 27485349 PMCID: PMC4969648 DOI: 10.1186/s12913-016-1553-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 07/12/2016] [Indexed: 02/07/2023] Open
Abstract
Background Healthcare providers-related disparities in adherence to the treatment plan among lymphoma patients are found even in a universal healthcare system, but the mechanism remains unclear. We investigated the association between the type of care center and the relative dose intensity and determined whether it persists after adjustment for patients’ recruitment differences. Methods Prospective observational cohort study of 294 patients treated with standard protocols for diffuse large B-cell lymphoma (DLBCL) in teaching or community public hospitals or in private centers in the French Midi-Pyrénées region from 2006–2013. To test our assumptions, we used multinomial and mixed-effect logistic models progressively adjusted for patients’ biomedical characteristics, socio-spatial characteristics and treatment-related toxicity events. Results Patients treated using standard protocols in the teaching hospital had more advanced stage and poorer initial prognosis without limitation regarding the distance from the residence to the care center. Patients’ recruitment profile across the different types of care center failed to explain the difference in relative dose intensity. Low relative dose intensity was less often observed in teaching hospital than elsewhere. Conclusion We showed that even in a universal healthcare system, disparities in the management of DLBCL patients’ do exist according to the types of care center. A main issue may be to find and diffuse the reasons of this benefit in cancer management in the teaching hospital to the other centers.
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Affiliation(s)
- S Lamy
- University of Toulouse III Paul Sabatier, Toulouse, France. .,Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France. .,INSERM UMR1027 (The French National Institute of Health and Medical Research), Toulouse, France.
| | - C Bettiol
- Department of Hematology, Toulouse University Hospital, Toulouse University Cancer Institute (IUCT-O), Toulouse, France
| | - P Grosclaude
- INSERM UMR1027 (The French National Institute of Health and Medical Research), Toulouse, France.,Tarn Cancers Registry, Albi, France
| | - G Compaci
- Department of Hematology, Toulouse University Hospital, Toulouse University Cancer Institute (IUCT-O), Toulouse, France
| | - G Albertus
- INSERM UMR1027 (The French National Institute of Health and Medical Research), Toulouse, France
| | - C Récher
- University of Toulouse III Paul Sabatier, Toulouse, France.,Department of Hematology, Toulouse University Hospital, Toulouse University Cancer Institute (IUCT-O), Toulouse, France.,INSERM UMR1037 (The French National Institute of Health and Medical Research), Cancer Research Center of Toulouse, Toulouse, France
| | - J C Nogaro
- Department of Hematology, Toulouse University Hospital, Toulouse University Cancer Institute (IUCT-O), Toulouse, France
| | - F Despas
- University of Toulouse III Paul Sabatier, Toulouse, France.,Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,INSERM UMR1027 (The French National Institute of Health and Medical Research), Toulouse, France
| | - G Laurent
- University of Toulouse III Paul Sabatier, Toulouse, France.,Department of Hematology, Toulouse University Hospital, Toulouse University Cancer Institute (IUCT-O), Toulouse, France.,INSERM UMR1037 (The French National Institute of Health and Medical Research), Cancer Research Center of Toulouse, Toulouse, France
| | - C Delpierre
- INSERM UMR1027 (The French National Institute of Health and Medical Research), Toulouse, France
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Salazar MC, Rosen JE, Arnold BN, Thomas DC, Kim AW, Detterbeck FC, Blasberg JD, Boffa DJ. Adjuvant Chemotherapy for T3 Non–Small Cell Lung Cancer with Additional Tumor Nodules in the Same Lobe. J Thorac Oncol 2016; 11:1090-100. [DOI: 10.1016/j.jtho.2016.03.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/01/2016] [Accepted: 03/04/2016] [Indexed: 11/30/2022]
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56
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Olszewski AJ, Fallah J, Castillo JJ. Human immunodeficiency virus-associated lymphomas in the antiretroviral therapy era: Analysis of the National Cancer Data Base. Cancer 2016; 122:2689-97. [DOI: 10.1002/cncr.30112] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/10/2016] [Accepted: 02/16/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Adam J. Olszewski
- Department of Medicine; Alpert Medical School of Brown University; Providence Rhode Island
| | - Jaleh Fallah
- Department of Medicine; Memorial Hospital of Rhode Island; Pawtucket Rhode Island
| | - Jorge J. Castillo
- Department of Medicine; Harvard Medical School; Boston Massachusetts
- Division of Hematologic Oncology, Dana-Farber Cancer Institute; Boston Massachusetts
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Rose TL, Deal AM, Nielsen ME, Smith AB, Milowsky MI. Sex disparities in use of chemotherapy and survival in patients with advanced bladder cancer. Cancer 2016; 122:2012-20. [PMID: 27224661 DOI: 10.1002/cncr.30029] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 10/30/2015] [Accepted: 12/17/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Women with advanced bladder cancer have inferior survival compared with men. However, women treated on clinical trials do not appear to have a survival disadvantage. Less frequent administration of systemic chemotherapy in women with advanced bladder cancer may contribute to their inferior survival. METHODS The authors identified patients diagnosed with stage IV bladder cancer from 1998 through 2010 using the National Cancer Data Base, a national outcomes database that includes 70% of all newly diagnosed cancer cases in the United States. Sex differences in demographics, systemic chemotherapy administration, and overall survival (OS) were compared. RESULTS A total of 23,981 patients were identified (35% of whom were female). Compared with men, women were older, more likely to be black, and less likely to be insured (P<.01 for all). The Charlson-Deyo comorbidity score did not differ between men and women. Women were less likely to receive systemic chemotherapy than men (45% vs 52%; adjusted relative risk, 0.91 [95% confidence interval (95% CI), 0.88-0.94]). Women had a lower median OS compared with men (8.0 months [95% CI, 7.7-8.3 months] vs 9.8 months [95% CI, 9.5-10.0 months]; P<.001). OS remained lower for women on multivariable analysis, even after adjusting for the administration of systemic chemotherapy (hazard ratio for death, 1.11 [95% CI, 1.08-1.15]). CONCLUSIONS Women are less likely than men to receive systemic chemotherapy for advanced bladder cancer and this difference may partially account for the poorer OS observed in women. However, OS remains lower in women independent of chemotherapy use, and may be related to unmeasured comorbidities, functional status, or tumor biology. Cancer 2016;122:2012-20. © 2016 American Cancer Society.
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Affiliation(s)
- Tracy L Rose
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Allison M Deal
- Biostatistics and Clinical Data Management Core, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Matthew E Nielsen
- Urologic Oncology Program, Department of Urology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Angela B Smith
- Urologic Oncology Program, Department of Urology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Matthew I Milowsky
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
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Abstract
Hodgkin's lymphoma (HL) is a relatively rare disease accounting for 15 % of all lymphoma. This disease has developed from an incurable disease to the adult malignancy with the most favorable prognosis. With current therapeutic approaches consisting of polychemo- and small-field radiotherapy, up to 80 % of all patients can be cured long term. In refractory or relapsed HL, intensified treatment including high-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT) is associated with progression-free survival (PFS) of 50 %. Evaluation of novel drugs in multiple relapsed or refractory cases, better treatment options for elderly patients and reducing treatment-related side effects are the main focus of current research. Recent clinical developments and future approaches in the treatment of HL will be discussed in this review.
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Hodgkin Lymphoma: the Changing Role of Radiation Therapy in Early-Stage Disease—the Role of Functional Imaging. Curr Treat Options Oncol 2016; 16:45. [PMID: 26187795 DOI: 10.1007/s11864-015-0360-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Early-stage classical Hodgkin lymphoma (CHL) is a highly curable malignancy. Historically, extended-field radiotherapy (EFRT) alone showed excellent cure rates, but the risk of radiotherapy (RT)-associated toxicities led to combined modality therapy (CMT) replacing RT alone. RT has subsequently evolved further with significant reductions of dose and field size, and is currently restricted to involved sites only (ISRT). Contemporary CMT yields cure rates in excess of 85%, and most studies do not have adequate follow-up required to evaluate the risk reduction in late effects. In an effort to avoid RT altogether, response-adapted treatment approaches utilizing results of interim [(18)F]fluorodeoxyglucose (FDG) positron emission tomography with fused computed tomography (PET/CT) imaging have been studied. Results from two studies in favorable-risk (UK RAPID and EORTC H10F) and one in unfavorable-risk patients (EORTC H10U) suggest that omission of RT in patients with a negative interim PET/CT response (Deauville score ≤2) yields slightly inferior progression-free survival (PFS) compared to conventional CMT, but with no difference in overall survival (OS) albeit with short-term follow-up. In order to extrapolate results to daily practice, it is critical to understand the selection of patients entered on trials since definitions of favorable and unfavorable disease vary between study groups. Currently, CMT continues to be the standard of care for the vast majority of patients with early-stage CHL and RT is an integral part of therapy in patients with bulky disease. However, for selected patients with favorable characteristics, emerging data suggest that a chemotherapy-alone approach is reasonable.
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60
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Treatment that follows guidelines closely dramatically improves overall survival of patients with anal canal and margin cancers. Crit Rev Oncol Hematol 2016; 101:131-8. [DOI: 10.1016/j.critrevonc.2016.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 01/10/2016] [Accepted: 03/01/2016] [Indexed: 02/02/2023] Open
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61
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In the Battle Between Protons and Photons for Hematologic Malignancies, the Patient Must Win. Int J Radiat Oncol Biol Phys 2016; 95:43-45. [DOI: 10.1016/j.ijrobp.2015.09.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/28/2015] [Indexed: 11/17/2022]
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62
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Ng AK, Dabaja BS, Hoppe RT, Illidge T, Yahalom J. Re-Examining the Role of Radiation Therapy for Diffuse Large B-Cell Lymphoma in the Modern Era. J Clin Oncol 2016; 34:1443-7. [DOI: 10.1200/jco.2015.64.9418] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Andrea K. Ng
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | | | - Timothy Illidge
- University of Manchester, Manchester Academic Health Sciences Centre, The Christie National Health Service Foundation Trust, Manchester, United Kingdom
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Abstract
OBJECTIVES Clinical series suggest favorable outcomes of HIV-associated Hodgkin lymphoma, in conflict with population-based statistics. Our objective was to investigate the proportion of Americans who received curative chemotherapy for this disease, and compare their survival with HIV-negative cases using population data. METHODS We selected cases of HIV-associated Hodgkin lymphoma diagnosed in 2004-2012 from the National Cancer Data Base. Factors associated with receipt of chemotherapy were analyzed by logistic regression. Overall survival was compared in proportional hazard models adjusting for available confounding factors. RESULTS Among 2090 HIV-positive patients, 81% received chemotherapy, but 16% received no treatment. Advanced age, male sex, nonwhite race, poor socioeconomic status, and undetermined histologic subtype were associated with higher risk of nontreatment. In 2012, 49% of HIV-positive patients were black, and 15% were Hispanic. Unadjusted 5-year overall survival was significantly lower for HIV-positive (66%) than for HIV-negative (80%) populations. However, among patients who received chemotherapy, HIV-positive status was not significantly associated with higher mortality in classical histologic subtypes, including nodular sclerosis (hazard ratio, HR, 1.08; 95% confidence interval, CI, 0.88-1.33) and mixed cellularity (HR, 1.06; 95% CI, 0.80-1.40). In contrast, prognosis remained significantly worse for cases with undetermined histology (HR, 1.56; 95% CI, 1.31-1.85), suggesting a more aggressive biology or other high-risk characteristics in this subgroup. CONCLUSION Worse survival statistics for HIV-associated Hodgkin lymphoma are driven by lower rates of chemotherapy administration. The disparity in treatment delivery needs attention because a majority of HIV-positive Americans with Hodgkin lymphoma are now black or Hispanic, and this proportion is increasing.
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Olszewski AJ, Falah J, Castillo JJ. Survival Claims From Observational Data on Cancer Therapy. J Clin Oncol 2016; 34:1425-7. [PMID: 26884574 DOI: 10.1200/jco.2015.64.7644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Adam J Olszewski
- Alpert Medical School of Brown University, Providence; and Memorial Hospital of Rhode Island, Pawtucket, RI
| | - Jaleh Falah
- Alpert Medical School of Brown University, Providence; and Memorial Hospital of Rhode Island, Pawtucket, RI
| | - Jorge J Castillo
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Keegan THM, DeRouen MC, Parsons HM, Clarke CA, Goldberg D, Flowers CR, Glaser SL. Impact of Treatment and Insurance on Socioeconomic Disparities in Survival after Adolescent and Young Adult Hodgkin Lymphoma: A Population-Based Study. Cancer Epidemiol Biomarkers Prev 2016; 25:264-73. [PMID: 26826029 PMCID: PMC4767568 DOI: 10.1158/1055-9965.epi-15-0756] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 12/04/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Previous studies documented racial/ethnic and socioeconomic disparities in survival after Hodgkin lymphoma among adolescents and young adults (AYA), but did not consider the influence of combined-modality treatment and health insurance. METHODS Data for 9,353 AYA patients ages 15 to 39 years when diagnosed with Hodgkin lymphoma during 1988 to 2011 were obtained from the California Cancer Registry. Using multivariate Cox proportional hazards regression, we examined the impact of sociodemographic characteristics [race/ethnicity, neighborhood socioeconomic status (SES), and health insurance], initial combined-modality treatment, and subsequent cancers on survival. RESULTS Over the 24-year study period, we observed improvements in Hodgkin lymphoma-specific survival by diagnostic period and differences in survival by race/ethnicity, neighborhood SES, and health insurance for a subset of more recently diagnosed patients (2001-2011). In multivariable analyses, Hodgkin lymphoma-specific survival was worse for Blacks than Whites with early-stage [HR: 1.68; 95% confidence interval (CI): 1.14-2.49] and late-stage disease (HR: 1.68; 95% CI, 1.17-2.41) and for Hispanics than Whites with late-stage disease (HR: 1.58; 95% CI, 1.22-2.04). AYAs diagnosed with early-stage disease experienced worse survival if they also resided in lower SES neighborhoods (HR: 2.06; 95% CI, 1.59-2.68). Furthermore, more recently diagnosed AYAs with public health insurance or who were uninsured experienced worse Hodgkin lymphoma-specific survival (HR: 2.08; 95% CI, 1.52-2.84). CONCLUSION Our findings identify several subgroups of Hodgkin lymphoma patients at higher risk for Hodgkin lymphoma mortality. IMPACT Identifying and reducing barriers to recommended treatment and surveillance in these AYAs at much higher risk of mortality is essential to ameliorating these survival disparities.
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Affiliation(s)
- Theresa H M Keegan
- Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California.
| | - Mindy C DeRouen
- Cancer Prevention Institute of California, Fremont, California
| | - Helen M Parsons
- Department of Epidemiology and Biostatistics, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Christina A Clarke
- Cancer Prevention Institute of California, Fremont, California. Department of Health Research and Policy (Epidemiology), Stanford University School of Medicine, Stanford, California
| | - Debbie Goldberg
- Cancer Prevention Institute of California, Fremont, California
| | - Christopher R Flowers
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sally L Glaser
- Cancer Prevention Institute of California, Fremont, California. Department of Health Research and Policy (Epidemiology), Stanford University School of Medicine, Stanford, California
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Maraldo MV, Ng AK. Minimizing Cardiac Risks With Contemporary Radiation Therapy for Hodgkin Lymphoma. J Clin Oncol 2016; 34:208-10. [DOI: 10.1200/jco.2015.64.6588] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Andrea K. Ng
- Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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Migdady Y, Salhab M, Dang NH, Markham MJ, Olszewski AJ. Disparities in conditional net survival among non-Hodgkin lymphoma survivors: a population-based analysis. Leuk Lymphoma 2015; 57:676-84. [PMID: 26428541 DOI: 10.3109/10428194.2015.1102246] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We evaluated the association of baseline prognostic factors with conditional net survival among survivors of six subtypes non-Hodgkin lymphoma using the SEER program data from 2000-2012. Among 2-year survivors, further prognosis markedly improved in Burkitt's (BL) and diffuse large B-cell lymphoma (DLBCL), and became the same as for follicular lymphoma (5-year net survival ≥ 85%). Mantle cell lymphoma (MCL) demonstrated the worst prognosis of all studied histologies up to 5 years of survivorship. Age and stage lost prognostic significance in BL within 2 years from diagnosis. Racial disparities in net survival disappeared within 2 years for all subtypes, except in chronic lymphocytic leukemia, where black patients had persistently worse prognosis, and in MCL, where they had unexpectedly better prognosis than other races after 2 years. Many baseline factors may lose their initial prognostic value for lymphoma survivors, which should be considered when counseling patients about their prognosis and long-term surveillance.
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Affiliation(s)
- Yazan Migdady
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Mohammed Salhab
- b University of Massachusetts Medical School , Worcester , MA , USA ;,c Memorial Hospital of Rhode Island , Pawtucket , RI , USA
| | - Nam H Dang
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Merry J Markham
- a Department of Medicine , University of Florida , Gainesville , FL , USA
| | - Adam J Olszewski
- c Memorial Hospital of Rhode Island , Pawtucket , RI , USA ;,d The Warren Alpert Medical School of Brown University , Providence , RI , USA
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Ling DC, Vargo JA, Balasubramani GK, Beriwal S. Underutilization of radiation therapy in early-stage marginal zone lymphoma negatively impacts overall survival. Pract Radiat Oncol 2015; 6:e97-e105. [PMID: 26852172 DOI: 10.1016/j.prro.2015.11.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 11/19/2015] [Accepted: 11/20/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE Multiple population-based studies have suggested increasing omission of radiation therapy in favor of alternative treatment strategies in lymphomas, with an associated negative impact on survival. Radiation therapy has long been considered the standard management for many mucosa-associated lymphoid tissue lymphomas. Thus, we aimed to evaluate patterns of treatment utilization and survival. METHODS AND MATERIALS A retrospective analysis based on the National Cancer Database was performed on 22,378 patients with splenic, nodal, or extranodal stage I-II marginal zone lymphoma diagnosed between 1998 and 2012. A logistic regression model was used to assess the association between sociodemographic, tumor, and treatment characteristics and the utilization of radiation therapy. Multivariate propensity score-adjusted Cox proportional hazards models were performed to identify factors independently associated with overall survival (OS). RESULTS Of 22,378 patients, 82% had stage I disease, 77% had extranodal mucosa-associated lymphoid tissue lymphoma, 5% had splenic marginal zone lymphoma, and 64% were older than 60 years. Radiation therapy utilization decreased from a peak of 39% in 2007 to 33% in 2011 (P < .001), with a corresponding significant increase in systemic therapy utilization. Radiation therapy was associated with a 5- and 10-year OS of 86.7% and 68.8% compared with 78.3% and 54.3% for no radiation therapy (P < .001). On multivariate propensity score-adjusted survival analysis, radiation therapy remained independently associated with improved OS (hazard of death, 0.75; 95% confidence interval, 0.65-0.85; P < .001). CONCLUSIONS Although clinical guidelines endorse radiation therapy as the preferred initial therapy for early-stage nongastric and Helicobacter pylori-negative gastric mucosa-associated lymphoid tissue lymphoma, radiation therapy is underused. Radiation therapy with or without systemic therapy was associated with a significant improvement in OS and should remain standard of care.
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Affiliation(s)
- Diane C Ling
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - John A Vargo
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Goundappa K Balasubramani
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
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Vargo JA, Gill BS, Balasubramani GK, Beriwal S. Treatment Selection and Survival Outcomes in Early-Stage Diffuse Large B-Cell Lymphoma: Do We Still Need Consolidative Radiotherapy? J Clin Oncol 2015; 33:3710-7. [DOI: 10.1200/jco.2015.61.7654] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The choice between chemotherapy alone and chemotherapy plus consolidative radiotherapy (RT) for diffuse large B-cell lymphoma (DLBCL) remains controversial. We aimed to define factors affecting treatment selection and the resulting survival outcomes. Patients and Methods Using the National Cancer Data Base, we identified 59,255 patients with stages I and II DLBCL treated with multiagent chemotherapy alone or chemotherapy plus consolidative RT between 1998 and 2012. Univariable and multivariable analyses were performed to identify sociodemographic, treatment, and tumor characteristics predictive of overall survival (OS) and treatment use. Propensity-adjusted Cox proportional hazard ratios for survival were used to account for indication bias. Results Of the 59,255 patients with DLBCL enrolled onto the study, 46% had stage II disease, 42% had extranodal disease, and 58% were more than 60 years of age. Only 39% received combined-modality therapy, and this proportion significantly declined from 47% in 2000 to 32% in 2012 (P < .001). Treatment selection was significantly influenced by race, comorbidity, insurance type, education quartile, facility type, age, stage, B symptoms, distance from treatment facility, and year of diagnosis. The median follow-up time was 60 months (interquartile range, 33 to 93). Estimated 5-year and 10-year OS rates were, respectively, 79% and 59% for all patients, 75% and 55% for patients receiving chemotherapy alone, and 82% and 64% for patients receiving combined-modality therapy (P < .001). Even after adjusting for immortal times and indication bias, combined-modality therapy was associated with better OS (HR, 0.66; 95% CI, 0.61 to 0.71; P < .001) than was chemotherapy alone. Conclusion Use of consolidative RT after multiagent chemotherapy in DLBCL is decreasing in the modern era. Selection of treatment strategy is affected by both classical prognostic features and socioeconomic factors. Abandonment of combined-modality therapy in favor of chemotherapy alone negatively affects patient survival.
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Affiliation(s)
- John A. Vargo
- John A. Vargo, Beant S. Gill, and Sushil Beriwal, University of Pittsburgh Cancer Institute; and Goundappa K. Balasubramani, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Beant S. Gill
- John A. Vargo, Beant S. Gill, and Sushil Beriwal, University of Pittsburgh Cancer Institute; and Goundappa K. Balasubramani, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Goundappa K. Balasubramani
- John A. Vargo, Beant S. Gill, and Sushil Beriwal, University of Pittsburgh Cancer Institute; and Goundappa K. Balasubramani, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Sushil Beriwal
- John A. Vargo, Beant S. Gill, and Sushil Beriwal, University of Pittsburgh Cancer Institute; and Goundappa K. Balasubramani, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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70
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Parikh RR, Grossbard ML, Harrison LB, Yahalom J. Early-Stage Classic Hodgkin Lymphoma: The Utilization of Radiation Therapy and Its Impact on Overall Survival. Int J Radiat Oncol Biol Phys 2015; 93:684-93. [DOI: 10.1016/j.ijrobp.2015.06.039] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 06/16/2015] [Accepted: 06/29/2015] [Indexed: 11/29/2022]
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71
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Olszewski AJ. Limits of registry data to understand survival disparities in lymphoma. LANCET HAEMATOLOGY 2015; 2:e459-60. [PMID: 26686253 DOI: 10.1016/s2352-3026(15)00188-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 08/25/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Adam J Olszewski
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA; Division of Haematology-Oncology, Memorial Hospital of Rhode Island, Pawtucket, RI 02860, USA.
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72
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Corso CD, Rutter CE, Park HS, Lester-Coll NH, Kim AW, Wilson LD, Husain ZA, Lilenbaum RC, Yu JB, Decker RH. Role of Chemoradiotherapy in Elderly Patients With Limited-Stage Small-Cell Lung Cancer. J Clin Oncol 2015; 33:4240-6. [PMID: 26481366 PMCID: PMC4678178 DOI: 10.1200/jco.2015.62.4270] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Purpose To investigate outcomes for elderly patients treated with chemotherapy (CT) alone versus chemoradiotherapy (CRT) in the modern era by using a large national database. Patients and Methods Elderly patients (age ≥ 70 years) with limited-stage small-cell lung cancer clinical stage I to III who received CT or CRT were identified in the National Cancer Data Base between 2003 and 2011. Hierarchical mixed-effects logistic regression with clustering by reporting facility was performed to identify factors associated with treatment selection. Overall survival (OS) of patients receiving CT versus CRT was compared by using the log-rank test, Cox proportional hazards regression, and propensity score matching. Results A total of 8,637 patients were identified, among whom 3,775 (43.7%) received CT and 4,862 (56.3%) received CRT. The odds of receiving CRT decreased with increasing age, clinical stage III disease, female sex, and the presence of medical comorbidities (all P < .01). Use of CRT was associated with increased OS compared with CT on univariable and multivariable analysis (median OS, 15.6 v 9.3 months; 3-year OS, 22.0% v 6.3%; log-rank P < .001; Cox P < .001). Propensity score matching identified a matched cohort of 6,856 patients and confirmed a survival benefit associated with CRT (hazard ratio, 0.52; 95% CI, 0.50 to 0.55; P < .001). Subset analysis of CRT treatment sequence showed that patients alive 4 months after diagnosis derived a survival benefit with concurrent CRT over sequential CRT (median OS, 17.0 v 15.4 months; log-rank P = .01). Conclusion In elderly patients with limited-stage small-cell lung cancer, modern CRT appears to confer an additional OS advantage beyond that achieved with CT alone in a large population-based cohort. Our findings suggest that CRT should be the preferred strategy in elderly patients who are expected to tolerate the toxicities of the combined approach.
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Affiliation(s)
| | | | - Henry S Park
- All authors: Yale University School of Medicine, New Haven, CT
| | | | - Anthony W Kim
- All authors: Yale University School of Medicine, New Haven, CT
| | - Lynn D Wilson
- All authors: Yale University School of Medicine, New Haven, CT
| | - Zain A Husain
- All authors: Yale University School of Medicine, New Haven, CT
| | | | - James B Yu
- All authors: Yale University School of Medicine, New Haven, CT
| | - Roy H Decker
- All authors: Yale University School of Medicine, New Haven, CT.
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Olszewski AJ, Foran JM. Health Insurance-Related Disparities in Lymphoma Survival Are Partly Mediated by Baseline Clinical Factors. Oncologist 2015; 20:1223-4. [PMID: 26432820 DOI: 10.1634/theoncologist.2015-0228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Adam J Olszewski
- Department of Medicine, Alpert Medical School, Brown University, Providence, Rhode Island, USA; Division of Hematology-Oncology, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island, USA
| | - James M Foran
- Division of Hematology and Medical Oncology, Mayo Clinic Florida, Jacksonville, Florida, USA
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Glaser SL, Clarke CA, Keegan THM, Chang ET, Weisenburger DD. Time Trends in Rates of Hodgkin Lymphoma Histologic Subtypes: True Incidence Changes or Evolving Diagnostic Practice? Cancer Epidemiol Biomarkers Prev 2015; 24:1474-88. [PMID: 26215294 PMCID: PMC4592457 DOI: 10.1158/1055-9965.epi-15-0281] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 07/20/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Histologic subtypes of classical Hodgkin lymphoma [cHL; e.g., nodular sclerosis, mixed cellularity, not otherwise specified (NOS)] are epidemiologically and prognostically distinctive. Therefore, unexplained, ongoing incidence rate declines for mixed cellularity and increases for NOS require examination. METHODS We analyzed detailed histology-specific Hodgkin lymphoma incidence rates in 1992 through 2011 U.S. SEER data (n = 21,372) and reviewed a regional subset of 2007 through 2011 NOS pathology reports for insight into diagnostic practices. RESULTS cHL rates were stable until 2007, then decreased for whites [annual percent change (APC) and 95% confidence interval (CI), -3.6% (-5.6% to -1.5%)]. Nodular sclerosis rates declined after 2007 by 5.9% annually, with variation by gender, age, and race/ethnicity. In 1992 through 2011, mixed cellularity rates declined [APC -4.0% (-4.7% to -3.3%)], whereas NOS rates rose [5.3% (4.5%-6.2%)] overall and in most patient groups. The 2007-2011 NOS age-specific rates were more similar to mixed cellularity rates for 1992-1996 than 2007-2011. Trends in combined rates were minimal, supporting increasing misclassification of mixed cellularity, lymphocyte depletion, and specific nodular sclerosis subtypes as NOS. Eighty-eight of 165 reviewed NOS pathology reports addressed classification choice. Twenty (12.1%) justified the classification, 21 (12.7%) described insufficient biopsy material, and coders missed specific subtype information for 27 (16.4%). CONCLUSION Recent nodular sclerosis rate declines largely represent true incidence changes. Long-term rate decreases for mixed cellularity and other less common subtypes, and increases for NOS (comprising ∼30% of cHL cases in 2011), likely reflect changes in diagnostic and/or classification practice. IMPACT Diminishing histologic subtyping undermines future surveillance and epidemiologic study of Hodgkin lymphoma. Guideline-based use of excisional biopsies and more coding quality control are warranted.
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Affiliation(s)
- Sally L Glaser
- Cancer Prevention Institute of California, Fremont, California. Department of Health Research and Policy (Epidemiology), Stanford University School of Medicine, Stanford, California.
| | - Christina A Clarke
- Cancer Prevention Institute of California, Fremont, California. Department of Health Research and Policy (Epidemiology), Stanford University School of Medicine, Stanford, California
| | - Theresa H M Keegan
- Cancer Prevention Institute of California, Fremont, California. Department of Health Research and Policy (Epidemiology), Stanford University School of Medicine, Stanford, California
| | - Ellen T Chang
- Department of Health Research and Policy (Epidemiology), Stanford University School of Medicine, Stanford, California. Health Sciences Practice, Exponent, Inc., Menlo Park, California
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Abstract
INTRODUCTION Over the past several decades, Hodgkin lymphoma (HL) has become a highly treatable lymphoid malignancy with excellent response rates and long-term disease-free survival. Late-toxicities, however, continue to be an area of significant concern. Recent studies have evaluated novel approaches to limit long-term toxicity without adversely impacting short-term survival. While early or interim PET scan has been correlated with PFS and OS in HL, the modification of therapy based on interim PET (response-adapted therapy) has been evaluated in retrospective and prospective cohorts. This paper will review evidence for the role of response-adapted therapy in HL. AREAS COVERED Data from completed and ongoing retrospective and prospective cohorts of HL patients were reviewed utilizing pubmed and clinicaltrials.org and pertinent studies culled to compile this review article. EXPERT OPINION While response-adapted therapy represents a promising area of research which may ultimately become standard-of-care, current data does not unequivocally endorse this approach, which should be used with caution outside of a clinical trial.
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Affiliation(s)
- Jesse Keller
- a 1 Washington University, Division of Oncology, Department of Medicine , St Louis, MO 63110, USA.,b 2 Washington University School of Medicine, Division of Oncology, Department of Internal Medicine , 660 S. Euclid Avenue, Campus Box 8056, St. Louis, MO 63110, USA +1 31 43 62 56 54 ; +1 31 44 54 79 41 ;
| | - Kenneth R Carson
- a 1 Washington University, Division of Oncology, Department of Medicine , St Louis, MO 63110, USA.,b 2 Washington University School of Medicine, Division of Oncology, Department of Internal Medicine , 660 S. Euclid Avenue, Campus Box 8056, St. Louis, MO 63110, USA +1 31 43 62 56 54 ; +1 31 44 54 79 41 ; .,c 3 Research Service, St. Louis Veterans Affairs Medical Center , 501 N. Grand Blvd Suite 300, St. Louis, MO 63103, USA
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Gill BS, Vargo JA, Pai SS, Balasubramani GK, Beriwal S. Management Trends and Outcomes for Stage I to II Mantle Cell Lymphoma Using the National Cancer Data Base: Ascertaining the Ideal Treatment Paradigm. Int J Radiat Oncol Biol Phys 2015; 93:668-76. [PMID: 26461009 DOI: 10.1016/j.ijrobp.2015.07.2265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/24/2015] [Accepted: 07/13/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE Mantle cell lymphoma (MCL) is a rare, albeit aggressive subset of non-Hodgkin lymphoma, resulting in varied treatment approaches. Given the paucity of data defining the optimal management for early-stage MCL, we conducted an analysis using the National Cancer Data Base (NCDB) to identify practice patterns and outcomes. METHODS AND MATERIALS The NCDB was queried for patients with stage I to II MCL diagnosed from 1998 to 2012 receiving chemotherapy (CT) or radiation therapy (RT), or both (CT+RT). Univariate and multivariable analyses for factors associated with treatment selection were completed using logistic regression. Propensity scores with inverse probability treatment weighting (IPTW) were calculated based on the conditional probability of receiving CT+RT. The log-rank test and Cox proportional hazards modeling with IPTW adjustment were conducted for the survival analyses. RESULTS In total, 2539 patients were identified. The key characteristics were as follows: 69% were male, 71% were aged ≥60 years, 28% had extranodal involvement, and 51% had stage I disease. Of the 2539 patients, 70% underwent CT, 11% underwent RT, and 19% underwent CT+RT. The use of CT+RT decreased from 23.1% to 14.1% in 1998 to 2002 and 2010 to 2012 (P<.001). CT+RT usage was lower for patients with the following characteristics: age ≥60 years, female sex, stage II disease, and the presence of B symptoms. With a median follow-up period of 42.8 months, the unadjusted 3-year overall survival estimates for patients receiving CT, RT, or CT+RT were 67.8%, 72.4%, and 79.8%, respectively (P<.001). After correcting for indication bias through IPTW-adjusted modeling, CT+RT reduced the risk of overall mortality compared with monotherapy (hazard ratio 0.65, P=.029). CONCLUSIONS Although uncommon, patients with stage I-II MCL can have favorable outcomes. Despite a continued decline in the usage of consolidative RT, combined modality therapy improves survival in this cohort compared with monotherapy.
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Affiliation(s)
- Beant S Gill
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - John A Vargo
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Sarah S Pai
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Goundappa K Balasubramani
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
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77
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Olszewski AJ, Shrestha R, Cook NM. Race-specific features and outcomes of nodular lymphocyte-predominant Hodgkin lymphoma: Analysis of the National Cancer Data Base. Cancer 2015; 121:3472-80. [PMID: 26149294 DOI: 10.1002/cncr.29527] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/02/2015] [Accepted: 03/20/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is higher among African Americans than among other races, but to the authors' knowledge, the characteristics of NLPHL in this population have not been evaluated. The authors compared clinical features, treatments, and survival of black and white patients with NLPHL using the National Cancer Data Base. METHODS The authors extracted the records of 602 black and 1950 white patients with NLPHL who were diagnosed between 1998 and 2011. Overall survival (OS) was compared using the log-rank test. RESULTS Black patients were on average younger than white patients (median age, 42 years vs 45 years; P =.0001), more often female (49% vs 29%; P<.0001), and more likely to have the axillary lymph nodes as the primary disease site (25% vs 17%; P =.0002). They also had unfavorable socioeconomic characteristics, a higher rate of no treatment in patients with early-stage disease, and a longer time to therapy initiation (median, 53.5 days vs 47 days; P<.0001). Despite this, the authors found no significant difference between the races with regard to stage distribution or survival (P =.39). OS at 7 years was 90.1% in patients with early-stage (American Joint Committee on Cancer stage IA/B, IIA) and 79.4% in patients with advanced stage (American Joint Committee on Cancer stage IIB, III/IV) NLPHL. Survival in the early stage of disease was not found to be significantly different after various treatment strategies (stratified log-rank P = .18), except that the administration of chemotherapy was associated with a better outcome in black patients (log-rank P =.011 vs P =.81 for white patients). CONCLUSIONS Differences in clinical presentation suggest the interaction of race-specific and sex-specific susceptibility factors for NLPHL. Further research is needed to elucidate these factors, and to investigate possible heterogeneous effects of treatments by race. Clinical trials comparing standard treatment strategies are unlikely to detect differences in OS among patients with early-stage NLPHL.
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Affiliation(s)
- Adam J Olszewski
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Department of Medicine, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island
| | - Rajesh Shrestha
- Department of Medicine, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island
| | - Nathaniel M Cook
- Division of Hematology-Oncology, Roger Williams Medical Center, Providence, Rhode Island
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Parikh RR, Grossbard ML, Green BL, Harrison LB, Yahalom J. Disparities in survival by insurance status in patients with Hodgkin lymphoma. Cancer 2015; 121:3515-24. [PMID: 26058564 DOI: 10.1002/cncr.29518] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 05/18/2015] [Accepted: 05/22/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND The association between insurance status and outcomes has not been well established for patients with Hodgkin lymphoma (HL). The purpose of this study was to examine the disparities in overall survival (OS) by insurance status in a large cohort of patients with HL. METHODS The National Cancer Data Base (NCDB) was used to evaluate patients with stage I to IV HL from 1998 to 2011. The association between insurance status, covariables, and outcomes was assessed in a multivariate Cox proportional hazards model. Survival was estimated with the Kaplan-Meier method. RESULTS Among the 76,681 patients within the NCDB, 45,777 patients with stage I to IV HL were eligible for this study (median follow-up, 6.0 years). The median age was 39 years (range, 18-90 years). The insurance status was as follows: 3247 (7.1%) were uninsured, 7962 (17.4%) had Medicaid, 30,334 (66.3%) had private insurance, 3746 (8.2%) had managed care, and 488 (1.1%) had Medicare. Patients with an unfavorable insurance status (Medicaid/uninsured) were at a more advanced stage, had higher comorbidity scores, had B symptoms, and were in a lower income/education quartile (all P < .01). These patients were less likely to receive radiotherapy and start chemotherapy promptly and were less commonly treated at academic/research centers (all P < .01). Patients with unfavorable insurance had a 5-year OS of 54% versus 87% for those favorably insured (P < .01). When adjustments were made for covariates, an unfavorable insurance status was associated with significantly decreased OS (hazard ratio, 1.60; 95% confidence interval, 1.34-1.91; P < .01). The unfavorable insurance status rate increased from 22.8% to 28.8% between 1998 and 2011. CONCLUSIONS This study reveals that HL patients with Medicaid and uninsured patients have outcomes inferior to those of patients with more favorable insurance. Targeting this subset of patients with limited access to care may help to improve outcomes. Cancer 2015;121:3435-43. © 2015 American Cancer Society.
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Affiliation(s)
- Rahul R Parikh
- Department of Radiation Oncology, Mount Sinai Beth Israel Medical Center, Mount Sinai Health System, New York, New York.,Department of Radiation Oncology, Mount Sinai Roosevelt Hospital, Mount Sinai Health System, New York, New York
| | - Michael L Grossbard
- Division of Hematology-Oncology, Laura and Isaac Perlmutter Cancer Center, New York University Langone Medical Center, New York, New York
| | - B Lee Green
- Division of Population Sciences, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Louis B Harrison
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Vargo JA, Gill BS, Balasubramani GK, Beriwal S. What is the optimal management of early-stage low-grade follicular lymphoma in the modern era? Cancer 2015; 121:3325-34. [PMID: 26042364 DOI: 10.1002/cncr.29491] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/02/2015] [Accepted: 04/30/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Despite international practice guidelines endorsing radiotherapy (RT) as the preferred initial therapy, treatment approaches vary for patients with early-stage follicular lymphoma. The authors engaged the National Cancer Data Base to analyze patterns of care and survival outcomes for patients with early-stage follicular lymphoma in the era of modern therapy. METHODS A National Cancer Data Base retrospective cohort study was conducted of 35,961 patients with lymph node and extranodal, American Joint Committee on Cancer stage I to II, WHO grade 1 to 2 follicular lymphoma who were diagnosed between 1998 and 2012. Univariate and multivariable analyses were performed to identify sociodemographic, treatment, and tumor characteristics that were predictive of overall survival (OS) and treatment use. Propensity score-adjusted Cox proportional hazards ratios for survival in patients treated for follicular lymphoma were used. RESULTS Of the 35,961 patients with follicular lymphoma included in the current study, 63% had stage I disease, 79% were without extranodal disease, and 61% were aged >60 years. RT use decreased from 37% in 1999 to 24% in 2012 (P<.0001), with corresponding significant increases in observation and single-agent chemotherapy. Patients who received RT had 5-year and 10-year OS rates of 86% and 68%, respectively, compared with 74% and 54%, respectively, for those who did not receive RT (P<.0001). On multivariable survival analysis, including a propensity score to account for potential uncaptured confounding variables due to a lack of randomization, upfront RT remained independently associated with improved OS (hazard ratio of death, 0.54; 95% confidence interval, 0.47-0.63 [P<.0001]). CONCLUSIONS RT is an increasingly underused treatment approach in the era of modern therapy for patients with early-stage follicular lymphoma. The use of RT appears to improve OS and should remain standard practice as encouraged by clinical practice guidelines.
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Affiliation(s)
- John A Vargo
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Beant S Gill
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Goundappa K Balasubramani
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
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