1
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Mijiti M, Wang C, Tian W, Shi Q, Zhang F, Abulaiti R, Qi X, Kou Z, Liu C, Wang Z, Zhai S, An L, Huang Q, Shao Y, Wufuer G, Li Y. Association between low incidence of TP53 mutations and reduced early relapse rates in Uygur DLBCL. Ann Hematol 2024:10.1007/s00277-024-05961-z. [PMID: 39187692 DOI: 10.1007/s00277-024-05961-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 08/19/2024] [Indexed: 08/28/2024]
Abstract
Diffuse large B-cell lymphoma (DLBCL) demonstrates significant heterogeneity, investigations into the distinctions in clinical and molecular characteristics between Chinese Uygur and Han DLBCL patients remain unexplored. We retrospectively reviewed 279 DLBCL patients (105 Uygur and 174 Han patients), of which 155 patients underwent genetic profiling by NGS. Compared with Han patient, Uygur patients have better clinical prognostic indicators, including a higher proportion of patients with 0-1 extranodal involvement and I/II Ann Arbor staging. Consistently, Uygur patients were significantly associated with lower risk of relapse (P = 0.06), with a one-year relapse rate of 5% vs 17% and two-year relapse rate of 19% vs 36% compared to Han patients. At the molecular level, TP53 (21.3%) was among the top frequently altered gene in the cohort. Notably, the Uygur patients exhibited a significantly lower frequency of TP53 alterations and higher frequency of ASXL3 alterations. Logistic regression analysis showed that the lowered frequency of TP53 and enrichment of ASXL3 in the Uygur patients were independent of other factors. However, only patients with TP53 mutations had higher relapse rate than those with wild type TP53 (one-year, 20% vs 10%; two-year, 51% vs 21%). Our findings highlight the notable contribution of a low TP53 mutation frequency in Uygur patients as a pivotal factor associated with the favorable prognosis of this population.
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Affiliation(s)
- Mutibaier Mijiti
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China
| | - Chun Wang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China
| | - Wenxin Tian
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China
| | - Qiping Shi
- Geneseeq Research Institute, Nanjing Geneseeq Technology Inc., Nanjing, Jiangsu, China
| | - Fang Zhang
- Department of Hematology, Chongzhou People's Hospital, Chengdu, Sichuan, China
| | - Renaguli Abulaiti
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China
| | - Xiaolong Qi
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China
| | - Zhen Kou
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China
| | - Cuicui Liu
- Geneseeq Research Institute, Nanjing Geneseeq Technology Inc., Nanjing, Jiangsu, China
| | - Zengsheng Wang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China
| | - Shunsheng Zhai
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China
| | - Li An
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China
| | - Qin Huang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China
| | - Yang Shao
- Geneseeq Research Institute, Nanjing Geneseeq Technology Inc., Nanjing, Jiangsu, China
| | - Guzailinuer Wufuer
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China
| | - Yan Li
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tianchi Road, Urumqi, 830011, Xinjiang Uygur Autonomous Region, China.
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2
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Khurana A, Mwangi R, Nastoupil LJ, Reagan PM, Farooq U, Romancik JT, McDonnell TJ, Riska SM, Lossos LS, Kahl BS, Martin P, Witzig TE, Cerhan JR, Flowers CR, Nowakowski GS, Maurer MJ. Evaluating the impact of laboratory-based eligibility criteria by race/ethnicity in first-line clinical trials of DLBCL. Blood Adv 2024; 8:4414-4422. [PMID: 38991126 PMCID: PMC11375257 DOI: 10.1182/bloodadvances.2024012838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 06/28/2024] [Accepted: 06/30/2024] [Indexed: 07/13/2024] Open
Abstract
ABSTRACT Underrepresentation of racial and ethnic subgroups in cancer clinical trials remains a persistent challenge. Restrictive clinical trial eligibility criteria have been shown to exacerbate this problem. We previously identified that up to 24% of patients treated with standard immunochemotherapy would have been excluded from recent first-line trials in diffuse large B-cell lymphoma (DLBCL) based on 5 laboratory-based criteria. These ineligible patients had worse clinical outcomes and increased deaths related to lymphoma progression, suggesting the potential exclusion of patients who could have benefited most from the novel therapies being evaluated. Using data from the prospectively enrolled Lymphoma Epidemiology Outcomes cohort study, with demographics broadly similar to the US patients diagnosed with lymphoma, we evaluated the impact of laboratory eligibility criteria from recent first-line DLBCL trials across various racial and ethnic backgrounds. There were significant differences in the baseline laboratory values by race/ethnicity with Black/African American (AA) patients having the lowest mean hemoglobin and highest creatinine clearance. Based on recent clinical trial eligibility criteria, AA and Hispanic patients had higher rates of laboratory-based ineligibility than non-Hispanic White patients. The largest gap in the clinical outcomes between eligible and noneligible patients was noted within AA patients with an overall survival hazard ratio based on POLARIX clinical trial criteria of 4.09 (95% confidence interval, 1.83-9.14). A thoughtful approach to the utility of each criterion and cutoffs for eligibility needs to be evaluated in the context of its differential impact across various racial/ethnic groups.
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Affiliation(s)
| | - Raphael Mwangi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | - Patrick M Reagan
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - Umar Farooq
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, University of Iowa, Iowa City, IA
| | - Jason T Romancik
- Department of Hematology and Medical Oncology, Winship Cancer Institute at Emory University, Atlanta, GA
| | - Timothy J McDonnell
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shaun M Riska
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Lzidore S Lossos
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami School of Medicine, Miami, FL
| | - Brad S Kahl
- Division of Oncology, Washington University School of Medicine, St. Louis, MO
| | - Peter Martin
- Division of Hematology Oncology, Meyer Cancer Center, Weill Cornell Medicine and New York Presbyterian Hospital, New York, NY
| | | | - James R Cerhan
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | | | - Matthew J Maurer
- Division of Hematology, Mayo Clinic, Rochester, MN
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
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3
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Ta A, Kaur S, Mader M, Franklin K, Williams M, Williams R, Blaize JP, Naqvi A, Ananth S, Song M, Warnecke BO, Pandya A, Djoumessi LRD, Nazarewicz P, Espinoza-Gutarra M, Lucero KT, Whitehead J, Al-Abayechi A, Boyle L, Lee S, Roman Souza G, Toro Velez E, Mines I, Nooruddin Z. The impact of race and ethnicity on diffuse large B-cell lymphoma outcomes within the veterans health administration (VHA). Leuk Lymphoma 2024; 65:1090-1099. [PMID: 38619488 DOI: 10.1080/10428194.2024.2338856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/31/2024] [Indexed: 04/16/2024]
Abstract
We performed a retrospective chart review of 6266 randomly selected DLBCL patients treated in the VHA nationwide between 1/1/2011 and 12/31/2021. The 3178 patients who met inclusion criteria were predominantly male (97%) and white (75%). Median age of diagnosis for Black patients was 63 years vs 69 years for the entire cohort (p < 0.001). However, patients in each race/ethnicity subgroup presented with similar rates of stage I/II and III/IV disease, IPI score, cell of origin and HIT status. Outcomes analysis revealed similar treatment, response rates, median overall survival, and 1-, 3-, and 5-year survival across all subgroups. Hispanic patients had a 21% lower risk of death (HR = 0.79) than white patients, and Black patients had no significant difference in survival (HR = 0.98). This large retrospective study shows that when standard of care therapy is given within an equal access system, short-term treatment and survival outcomes are the same for all races.
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Affiliation(s)
- Andrew Ta
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Supreet Kaur
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Michael Mader
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | | | | | - Ryan Williams
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Amna Naqvi
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Snegha Ananth
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | | | - Brian Oliver Warnecke
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Abhishek Pandya
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Lakene Raissa Djoufack Djoumessi
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | | | - Manuel Espinoza-Gutarra
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kana Tai Lucero
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | | | - Alaq Al-Abayechi
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Lauren Boyle
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Sophia Lee
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Gabriel Roman Souza
- Department of Hematology and Medical Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Esteban Toro Velez
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Ian Mines
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Zohra Nooruddin
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
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4
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Jin Y, Li J, Mun Y, Masaquel A, Hu S, Biondo JML. Association of race/ethnicity and insurance with survival in patients with diffuse large B-cell lymphoma in a large real-world cohort. Cancer Med 2024; 13:e70032. [PMID: 39177019 PMCID: PMC11342043 DOI: 10.1002/cam4.70032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 01/19/2024] [Accepted: 07/08/2024] [Indexed: 08/24/2024] Open
Abstract
The large real-world EHR dataset Flatiron has shown that race was not significantly associated with poorer survival in patients with DLBCL. Medicaid insurance status was significantly associated with poorer overall survival and time to second-line therapy or death due to any cause in patients with DLBCL aged <65 years.
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Affiliation(s)
- Yanling Jin
- F. Hoffmann‐La Roche LtdMississaugaOntarioCanada
| | - Jia Li
- Genentech, Inc.South San FranciscoCaliforniaUSA
| | - Yong Mun
- Genentech, Inc.South San FranciscoCaliforniaUSA
| | | | - Sylvia Hu
- Genentech, Inc.South San FranciscoCaliforniaUSA
- Present address:
Data Solutions LLCBronxNew YorkUSA
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5
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Chen X, Shukla M, Saint Fleur-Lominy S. Disparity in hematological malignancies: From patients to health care professionals. Blood Rev 2024; 65:101169. [PMID: 38220565 DOI: 10.1016/j.blre.2024.101169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/16/2024]
Abstract
In the recent few decades, outcomes in patients diagnosed with hematological malignancies have been steadily improving. However, the improved prognosis does not distribute equally among patients from different backgrounds. Besides cancer biology, demographic and geographic disparities have been found to impact overall survival significantly. Specifically, patients from underrepresented minorities including Black and Hispanics, and those with uninsured status, having low socioeconomic status, or from rural areas have had worse outcomes historically, which is uniformly true across all major subtypes of hematological malignancies. Similar discrepancy is also seen in the health care professional field, where a gender gap and a disproportionally low representation of health care providers from underrepresented minorities have been long existing. Thus, a comprehensive strategy to mitigate disparity in the health care system is needed to achieve equity in health care.
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Affiliation(s)
- Xiaoyi Chen
- Department of Medicine, Division of Hematology and Medical Oncology, New York University, Grossman School of Medicine, NY, New York, USA.
| | - Mihir Shukla
- Department of Medicine, Division of Hematology and Medical Oncology, New York University, Grossman School of Medicine, NY, New York, USA.
| | - Shella Saint Fleur-Lominy
- Department of Medicine, Division of Hematology and Medical Oncology, New York University, Grossman School of Medicine, NY, New York, USA; Perlmutter Cancer Center, NYU Langone Health, NY, New York, USA.
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6
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Iftikhar R, Ahmad U, Haider G, Mahmood H, Khan M, Masood M, Anwar N, Javed Q, Sajid N, Tariq R, Mehmod S, Haider J, Abro NA, Shahbaz S, Khokhar A, Khan ZA, Pervez H, Moosajee M, Aziz Z. Real-World Challenges of Managing Diffuse Large B-Cell Lymphoma in a Developing Country. JCO Glob Oncol 2024; 10:e2300386. [PMID: 38603657 DOI: 10.1200/go.23.00386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/26/2023] [Accepted: 02/20/2024] [Indexed: 04/13/2024] Open
Abstract
PURPOSE To highlight challenges and cancer care disparities in patients of diffuse large B-cell lymphoma management in resource-constrained settings. MATERIALS AND METHODS This multicenter retrospective study included 738 patients from 12 public and private sector hematology-oncology centers across Pakistan. Patients were divided into limited-resource and enhanced-resource settings as per national diffuse large B-cell lymphoma (DLBCL) guidelines. RESULTS The median age at diagnosis was 47 years (range, 14-89). Male:female ratio was 2.5:1. Majority of the patients (69.3%) were treated in limited-resource settings. Computed tomography was used as a staging modality in 442 (60%) patients. Limited-stage DLBCL was present in 13.5% of patients, while 86.3% had advanced-stage disease at diagnosis. First-line regimens included rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone in 56% and cyclophosphamide, doxorubicin, vincristine, prednisone in 34% of patients, while 10% of patients received palliative regimens upfront. Of evaluable data, complete remission was documented in 299 (74.4%) patients, 39 (9.8%) had partial response and 63 (13.5%) had progressive disease. Disease-free survival (DFS) and overall survival (OS) status were not available for 345 (46.8%) patients at the time of data collection. Overall study cohort had a median follow-up of 2.2 years with a median OS of 3.6 years (95% CI, 3.1 to 4.1), median DFS of 3.1 years (95% CI, 2.6 to 3.6), and a 5-year OS of 40% and DFS of 36%. CONCLUSION Patients from low- and middle-income countries present at an earlier age and have more advanced disease. Patients were frequently lost to follow-up, and record keeping was inadequate more so in patients treated in limited-resource settings. There is a need to establish a national lymphoma registry, improve record keeping, and standardize treatments to ensure improvement in treatment outcomes.
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Affiliation(s)
- Raheel Iftikhar
- Armed Forces Bone Marrow Transplant Center, Rawalpindi, Pakistan
| | - Usman Ahmad
- Shoukat Khanam Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Ghulam Haider
- Jinnah Post Graduate Medical Centre, Karachi, Pakistan
| | - Humera Mahmood
- Nuclear Medicine, Oncology and Radiotherapy Institute, Rawalpindi, Pakistan
| | - Maryam Khan
- Armed Forces Bone Marrow Transplant Center, Rawalpindi, Pakistan
| | - Misbah Masood
- Institute of Nuclear Medicine and Oncology, Lahore, Pakistan
| | - Nida Anwar
- National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, Pakistan
| | | | - Nadia Sajid
- Institute of Nuclear Medicine and Oncology, Lahore, Pakistan
| | - Rija Tariq
- Institute of Nuclear Medicine and Oncology, Lahore, Pakistan
| | - Sana Mehmod
- Nuclear Medicine, Oncology and Radiotherapy Institute, Rawalpindi, Pakistan
| | - Javeria Haider
- Nuclear Medicine, Oncology and Radiotherapy Institute, Rawalpindi, Pakistan
| | | | - Shanzah Shahbaz
- Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, Pakistan
| | | | | | | | | | - Zeba Aziz
- Hameed Latif Hospital, Lahore, Pakistan
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7
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Cerchietti L. Genetic mechanisms underlying tumor microenvironment composition and function in diffuse large B-cell lymphoma. Blood 2024; 143:1101-1111. [PMID: 38211334 PMCID: PMC10972714 DOI: 10.1182/blood.2023021002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/18/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024] Open
Abstract
ABSTRACT Cells in the tumor microenvironment (TME) of diffuse large B-cell lymphoma (DLBCL) show enormous diversity and plasticity, with functions that can range from tumor inhibitory to tumor supportive. The patient's age, immune status, and DLBCL treatments are factors that contribute to the shaping of this TME, but evidence suggests that genetic factors, arising principally in lymphoma cells themselves, are among the most important. Here, we review the current understanding of the role of these genetic drivers of DLBCL in establishing and modulating the lymphoma microenvironment. A better comprehension of the relationship between lymphoma genetic factors and TME biology should lead to better therapeutic interventions, especially immunotherapies.
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Affiliation(s)
- Leandro Cerchietti
- Hematology and Oncology Division, Medicine Department, New York-Presbyterian Hospital, Meyer Cancer Center, Weill Cornell Medicine, Cornell University, New York, NY
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8
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Cerhan JR, Maurer MJ, Link BK, Feldman AL, Habermann TM, Jaye DL, Burack WR, McDonnell TJ, Vega F, Chapman JR, Syrbu S, Vij KR, Inghirami G, Leonard JP, Bernal-Mizrachi L, Farooq U, Witzig TE, Weiner GJ, Wang Y, Alderuccio JP, Slager SL, Larson MC, Riska SM, Gysbers BJ, Lunde JJ, Reicks TW, Ayers AA, O’Leary CB, Yost KJ, Liu H, Nowakowski GS, Ruan J, Chihara D, Koff JL, Casulo C, Thompson CA, Cohen JB, Kahl BS, Nastoupil LJ, Lossos IS, Friedberg JW, Martin P, Flowers CR. The Lymphoma Epidemiology of Outcomes cohort study: Design, baseline characteristics, and early outcomes. Am J Hematol 2024; 99:408-421. [PMID: 38217361 PMCID: PMC10981429 DOI: 10.1002/ajh.27202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/15/2024]
Abstract
To address the current and long-term unmet health needs of the growing population of non-Hodgkin lymphoma (NHL) patients, we established the Lymphoma Epidemiology of Outcomes (LEO) cohort study (NCT02736357; https://leocohort.org/). A total of 7735 newly diagnosed patients aged 18 years and older with NHL were prospectively enrolled from 7/1/2015 to 5/31/2020 at 8 academic centers in the United States. The median age at diagnosis was 62 years (range, 18-99). Participants came from 49 US states and included 538 Black/African-Americans (AA), 822 Hispanics (regardless of race), 3386 women, 716 age <40 years, and 1513 rural residents. At study baseline, we abstracted clinical, pathology, and treatment data; banked serum/plasma (N = 5883, 76.0%) and germline DNA (N = 5465, 70.7%); constructed tissue microarrays for four major NHL subtypes (N = 1189); and collected quality of life (N = 5281, 68.3%) and epidemiologic risk factor (N = 4489, 58.0%) data. Through August 2022, there were 1492 deaths. Compared to population-based SEER data (2015-2019), LEO participants had a similar distribution of gender, AA race, Hispanic ethnicity, and NHL subtype, while LEO was underrepresented for patients who were Asian and aged 80 years and above. Observed overall survival rates for LEO at 1 and 2 years were similar to population-based SEER rates for indolent B-cell (follicular and marginal zone) and T-cell lymphomas, but were 10%-15% higher than SEER rates for aggressive B-cell subtypes (diffuse large B-cell and mantle cell). The LEO cohort is a robust and comprehensive national resource to address the role of clinical, tumor, host genetic, epidemiologic, and other biologic factors in NHL prognosis and survivorship.
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Affiliation(s)
- James R. Cerhan
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew J. Maurer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brain K. Link
- Department of Internal Medicine, Division of Hematology, Oncology, and Bone & Marrow Transplantation, University of Iowa, Iowa City, Iowa, USA
| | - Andrew L. Feldman
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David L. Jaye
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
| | - W. Richard Burack
- Department of Pathology, University of Rochester, Rochester, New York, USA
| | - Timothy J. McDonnell
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Francisco Vega
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer R. Chapman
- Department of Pathology, Division of Hematopathology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Sergei Syrbu
- Department of Pathology, University of Iowa, Iowa City, Iowa, USA
| | - Kiran R. Vij
- Department of Pathology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Giorgio Inghirami
- Department of Pathology, Weill Cornell Medicine, New York, New York, USA
| | - John P. Leonard
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Leon Bernal-Mizrachi
- Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia, USA
| | - Umar Farooq
- Department of Internal Medicine, Division of Hematology, Oncology, and Bone & Marrow Transplantation, University of Iowa, Iowa City, Iowa, USA
| | - Thomas E. Witzig
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - George J. Weiner
- Department of Internal Medicine, Division of Hematology, Oncology, and Bone & Marrow Transplantation, University of Iowa, Iowa City, Iowa, USA
| | - Yucai Wang
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan P. Alderuccio
- Department of Medicine, Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Susan L. Slager
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Melissa C. Larson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Shaun M. Riska
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Brianna J. Gysbers
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Julianne J. Lunde
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Tanner W. Reicks
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy A. Ayers
- Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia, USA
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Colin B. O’Leary
- Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia, USA
| | - Kathleen J. Yost
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Hongfang Liu
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jia Ruan
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Dai Chihara
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jean L. Koff
- Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia, USA
| | - Carla Casulo
- Wilmot Cancer Institute, University of Rochester, Rochester, New York, USA
| | - Carrie A. Thompson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathon B. Cohen
- Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia, USA
| | - Brad S. Kahl
- Division of Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Loretta J. Nastoupil
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Izidore S. Lossos
- Department of Medicine, Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | | | - Peter Martin
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Christopher R. Flowers
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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9
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Ermann DA, Vardell VA, Shah H, Fitzgerald L, Tao R, Gaffney DK, Stephens DM, Hu B. Survival Outcomes of Limited-Stage Diffuse Large B-Cell Lymphoma Treated With Radiation Therapy. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:94-104.e6. [PMID: 38000981 DOI: 10.1016/j.clml.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Patients with favorable risk limited-stage (LS) diffuse large b-cell lymphoma (DLBCL) have shown excellent outcomes without radiotherapy (RT). However, the role of RT for the remainder of LS-DLBCL patients is less well defined. We aimed to investigate whether the addition of RT provided an overall survival (OS) benefit in a real-world cohort of LS-DLBCL patients based on primary site at presentation. MATERIALS AND METHODS Retrospective data from 39,745 patients with stage I and II DLBCL treated with front-line combination chemotherapy alone or followed by RT were identified using the National Cancer Database from 2004 to 2015. RESULTS The addition of RT was associated with improved 5-year OS for all LS patients as compared to those treated with chemotherapy alone (85% vs. 80%, P < .001). RT was associated with improved 5-year OS in both the nodal and extranodal disease patients (nodal: 85% vs. 80%, P < .001; extranodal: 83% vs. 79%; P < .001). Extranodal sites with prolonged OS from the addition of RT include skin and soft tissue, head and neck, testicular, and thyroid sites (all P < .02). Breast, bone, lung and gastrointestinal extranodal primary sites had no OS benefit from the inclusion of RT. In multivariate analysis, the addition of RT was an independent factor for improved survival for all LS patients ([HR] 0.84, 95% [CI] 0.81-0.88; P < .001). CONCLUSION Though there is no consensus on optimal treatment indications for RT in LS-DLBCL, these data suggest certain subgroups may have benefit when RT is added to front-line chemotherapy.
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Affiliation(s)
- Daniel A Ermann
- Department of Hematology/Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | - Harsh Shah
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Lindsey Fitzgerald
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Randa Tao
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Deborah M Stephens
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Boyu Hu
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT.
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10
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Arya S, Mozessohn L, Gong I, Faught N, Liu N, Singh S, Chan K, Cheung MC. The impact of marginalization on diffuse large B-cell lymphoma overall survival: a retrospective cohort study. Leuk Lymphoma 2024:1-9. [PMID: 38265355 DOI: 10.1080/10428194.2024.2306463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/12/2024] [Indexed: 01/25/2024]
Abstract
The aim of this study was to describe the impact of marginalization on DLBCL overall survival (OS) within the Canadian setting. We conducted a population-based retrospective cohort study of adult patients with newly diagnosed DLBCL in Ontario between 1 January 2005 and 31 December 2017 receiving a rituximab-containing chemotherapy regimen with curative intent followed until 1 March 2020. Our primary exposure of interest was the Ontario Marginalization Index (ON-Marg). The primary outcome was 2-year OS, accounting for patient age, sex, cancer characteristics, comorbidity burden, and rural dwelling status. While two-year overall survival was inferior for individuals in the most deprived marginalization quintile (70.4% Q5 vs. 76.0% Q1), after adjustment for relevant covariates neither the composite ON-Marg nor any of its dimensions had a significant effect. Within the Canadian context, among patients who receive chemotherapy, marginalization may not have a significant association with overall survival when accounting for key patient covariates, lending support for preserved outcomes.
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Affiliation(s)
- Sumedha Arya
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lee Mozessohn
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Inna Gong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Simron Singh
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Kelvin Chan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Matthew C Cheung
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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11
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Bodla ZH, Hashmi M, Niaz F, Farooq U, Khalid F, Tariq MJ, Khalil MJ, Brown VS, Bray CL. Independent predictors of mortality and 5-year trends in mortality and resource utilization in hospitalized patients with diffuse large B cell lymphoma. Proc AMIA Symp 2023; 37:16-24. [PMID: 38174025 PMCID: PMC10761168 DOI: 10.1080/08998280.2023.2267921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 09/24/2023] [Indexed: 01/05/2024] Open
Abstract
Background This retrospective study analyzed factors influencing all-cause inpatient mortality in 80,930 adult patients (2016-2020) with diffuse large B cell lymphoma using the National Inpatient Sample database. Methods Utilizing ICD-10 codes, patients were identified, and statistical analysis was conducted using STATA. Fisher's exact and Student's t tests compared proportions and variables, multivariate logistic regression examined mortality predictors, and a 5-year longitudinal analysis identified mortality and resource utilization trends. Results The inpatient mortality rate was found to be 6.56% with a mean age of 67.99 years. Several hospital- and patient-level factors including specific comorbidities such as congestive heart failure, atrial fibrillation, acute kidney injury, chronic obstructive pulmonary disease, liver failure, pancytopenia, tumor lysis syndrome, and severe protein-calorie malnutrition were independently associated with inpatient mortality. Hospitalization costs showed an increasing trend, impacting the overall population and survivors. Conclusion These insights may refine risk assessment, treatment selection, and interventions.
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Affiliation(s)
- Zubair Hassan Bodla
- University of Central Florida College of Medicine, Graduate Medical Education, Orlando, Florida, USA
- HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, Florida, USA
| | - Mariam Hashmi
- HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, Florida, USA
| | - Fatima Niaz
- King Edward Medical University, Lahore, Punjab, Pakistan
- Mayo Hospital, Lahore, Punjab, Pakistan
| | - Umer Farooq
- Rochester Regional Health, Rochester, New York, USA
| | - Farhan Khalid
- Monmouth Medical Center, Long Branch, New Jersey, USA
| | | | | | - Victoria S. Brown
- Florida Cancer Specialists and Research Institute, Gainesville, Florida, USA
| | - Christopher L. Bray
- University of Central Florida College of Medicine, Graduate Medical Education, Orlando, Florida, USA
- HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, Florida, USA
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12
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Arshad S, Fang X, Ahn KW, Kaur M, Scordo M, Sauter CS, Furqan F, Awan FT, Hamadani M. Impact of thiotepa dose-intensity in primary diffuse large B-cell lymphoma of the central nervous system undergoing autologous hematopoietic cell transplant with thiotepa/carmustine conditioning. Bone Marrow Transplant 2023; 58:1203-1208. [PMID: 37563283 PMCID: PMC11078515 DOI: 10.1038/s41409-023-02071-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/29/2023] [Accepted: 07/17/2023] [Indexed: 08/12/2023]
Abstract
Thiotepa/carmustine (TT-BCNU) is a commonly used autologous transplant (ASCT) conditioning regimen for primary DLBCL of the CNS (PCNSL). The total thiotepa dose varies among TT-BCNU recipients, with some centers administering a total dose of 20 mg/kg, while others using 10 mg/kg. We retrospectively assessed the impact of thiotepa dose intensity on ASCT outcomes in 218 adult PCNSL patients who underwent a first ASCT with TT-BCNU conditioning and received either a total thiotepa dose of 10 mg/kg (TT-10 group; N = 90), or 20 mg/kg (TT-20 group; N = 128). The median follow-up of survivors was 22 months. The cumulative incidence of 1-year non-relapse mortality (NRM) for TT-10 and TT-20 cohorts were 6% (95%CI = 2-12%) vs. 4% (95%CI = 1-8%), respectively (p = 0.66). The 3-year cumulative incidence of relapse (15% vs. 13%; p = 0.67), progression-free survival (PFS) (71% vs. 80%; p = 0.25) and overall survival (OS) (79% vs. 83%; p = 0.56) were similar in the TT-10 and TT-20 groups, respectively. On multivariate analysis compared to TT-10, the TT-20 cohort was not associated with significantly different risk of NRM (Hazard ration [HR] = 0.77; p = 0.64), relapse/progression (HR = 0.87; p = 0.74), PFS (HR = 0.80; p = 0.48) or OS (HR = 1.10; p = 0.80). In conclusion thiotepa dose-intensity in TT-BCNU conditioning does not impact ASCT outcomes of PCNSL patients.
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Affiliation(s)
- Shanze Arshad
- School of Medicine, University of Kentucky, Lexington, KY, USA
| | - Xi Fang
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kwang W Ahn
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Manmeet Kaur
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael Scordo
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Fateeha Furqan
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Farrukh T Awan
- Division of Hematology and Oncology, UT Southwestern, Dallas, TX, USA
| | - Mehdi Hamadani
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
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13
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Rosenberg M, Poluch M, Thomas C, Sindaco P, Khoo A, Porcu P. Hepatitis B Virus and B-cell lymphoma: evidence, unmet need, clinical impact, and opportunities. Front Oncol 2023; 13:1275800. [PMID: 37927464 PMCID: PMC10623156 DOI: 10.3389/fonc.2023.1275800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/09/2023] [Indexed: 11/07/2023] Open
Abstract
Nearly a billion people worldwide are infected with the hepatitis B Virus (HBV) and about a third of them have chronic infection. HBV is an important cause of morbidity and mortality, including acute and chronic hepatitis and hepatocellular carcinoma (HCC). Screening and control of primary HBV infection through vaccination represent a major advance in global public health, but large sections of the world population, in both developed and underdeveloped countries, remain unscreened and unvaccinated. In addition to being a global cause of liver disease, an important role of HBV in lymphoma has also emerged. First, the high risk of HBV reactivation in previously infected patients receiving chemo-immunotherapy necessitates the systematic evaluation of HBV serological status in all non-Hodgkin's lymphoma (NHL) cases and preemptive antiviral therapy for those who may have chronic or occult HBV infection. Second, HBV has been shown to infect lymphocytes, namely B-cells, and has been associated with a higher risk of developing B-cell lymphoma, most clearly in countries where HBV is endemic. While the risk of HBV reactivation with chemoimmunotherapy in NHL is well known, the role and the impact of HBV as a global lymphoma risk factor and potential oncogenic driver in B-cells are very poorly understood. Here, we review the clinical and scientific evidence supporting an association between HBV and B-cell lymphoma, with a particular focus on diffuse large B-cell lymphoma (DLBCL) and provide an overview of the estimated impact of HBV infection on the biology and clinical course of DLBCL. We also discuss ways to gain a better insight into the unmet need posed by HBV in lymphoma and whether assessing immune responses to HBV, measuring viral loads, and detecting the presence of HBV-encoded proteins in tumor tissue could be integrated into the molecular and clinical risk stratification of patients with DLBCL.
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Affiliation(s)
- Maya Rosenberg
- Department of Internal Medicine, New York University Langone Health, New York, NY, United States
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Maria Poluch
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Colin Thomas
- Department of Medical Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Paola Sindaco
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Alan Khoo
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Pierluigi Porcu
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, United States
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14
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Dhir A, Epperla N, Costa LJ, Xavier AC. Nonbiological factors affecting outcomes in adolescents and young adults with lymphoma. Front Public Health 2023; 11:1261066. [PMID: 37920585 PMCID: PMC10619724 DOI: 10.3389/fpubh.2023.1261066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023] Open
Abstract
The impact of nonbiological factors (NBF) on survival was investigated in a large cohort of adolescents and young adults (AYA) with lymphoma in the United States (US). We found that uninsured and Medicaid AYA beneficiaries with classical Hodgkin lymphoma (cHL) and non-Hodgkin lymphoma (NHL) are at significantly increased risk of death when compared with their insured counterpart even after adjustment for other factors affecting survival. Increased risk of death was also noted for Non-Hispanic Black (NHB) patients with cHL and NHL when compared to Non-Hispanic White (NHW) patients, however, only Hispanic patients with NHL were found to have a significantly increased mortality risk while those with cHL were not. NHL AYA patients residing in lower-income counties are at increased risk of death. The strong association of NBF with survival indicates opportunities to improve the survival of AYA lymphoma patients by improving access/quality of care in the US.
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Affiliation(s)
- Aditi Dhir
- Department of Pediatrics, Division of Hematology/Oncology, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Narendranath Epperla
- Department of Medicine, Division of Hematology, The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, United States
| | - Luciano J. Costa
- Department of Medicine, Division of Hematology and Medical Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ana C. Xavier
- Department of Pediatrics, Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
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15
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MacDougall K, Day S, Hall S, Zhao D, Pandey M, Ibrahimi S, Khawandanah M, Chakrabarty JH, Asch A, Nipp R, Al-Juhaishi T. Impact of Race and Age and their Interaction on Survival Outcomes in Patients With Diffuse Large B-Cell Lymphoma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:379-384. [PMID: 36813625 DOI: 10.1016/j.clml.2023.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Advances in treatment for patients with Diffuse Large B-Cell Lymphoma (DLBCL) have led to improved patient outcomes but the magnitude of these disparities remains understudied with regards to improved survival outcomes. We sought to describe changes in DLBCL survival trends over time and explore potential differential survival patterns by patients' race/ethnicity and age. METHODS We utilized the Surveillance, Epidemiology, and End Results (SEER) database to identify patients diagnosed with DLBCL from 1980 to 009 and determined 5-year survival outcomes for all patients, categorizing patients by year of diagnosis. We used descriptive statistics and logistic regression, adjusting for stage and year of diagnosis, to describe changes in 5-year survival rates over time by race/ethnicity and age. RESULTS We identified 43,564 patients with DLBCL eligible for this study. Median age was 67 years (ages: 18-64 = 44.2%, 65-79 = 37.1%, 80 + = 18.7%). Most patients were male (53.4%) and had advanced stage III/IV disease (40.0%). Most patients were White race (81.4%), followed by Asian/Pacific Islander (API) (6.3%), Black (6.3%), Hispanic (5.4%), and American Indian/Alaska Native (AIAN) (0.05%). Overall, the 5-year survival rate improved from 35.1% in 1980 to 52.4% in 2009 across all races and age groups (odds ratio [OR] for 5-year survival with increasing year of diagnosis = 1.05, P < .001). Patients in racial/ethnic minority groups (API: OR = 0.86, P < .0001; Black: OR = 0.57, P < .0001; AIAN: OR = 0.51, P = .008; Hispanic: 0.76, P = 0.291) and older adults (ages 65-79: OR = 0.43, P < .0001; ages 80+: OR = 0.13, P < .0001) had lower 5-year survival rates after adjusting for race, age, stage, and diagnosis year. We found consistent improvement in the odds of 5-year survival for year of diagnosis across all race and ethnicity groups (White: OR = 1.05, P < .001; API: OR = 1.04, P < .001; Black: OR = 1.06, p<.001; AIAN: OR = 1.05, P < .001; Hispanic: OR = 1.05, P < .005) and age groups (ages 18-64: OR = 1.06, P < .001; ages 65-79: OR = 1.04, P < .001; ages 80+: OR = 1.04, P < .001). CONCLUSION Patients with DLBCL experienced improvements in 5-year survival rates from 1980 to 2009, despite persistently lower survival among patients in racial/ethnic minority groups and older adults.
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Affiliation(s)
- Kira MacDougall
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma, OK
| | - Silas Day
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma, OK
| | - Spencer Hall
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma, OK; Stephenson Cancer Center Biostatistics Research and Design Core, Oklahoma, OK
| | - Daniel Zhao
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma, OK; Stephenson Cancer Center Biostatistics Research and Design Core, Oklahoma, OK
| | - Manu Pandey
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma, OK
| | - Sami Ibrahimi
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma, OK
| | - Mohamad Khawandanah
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma, OK
| | - Jennifer H Chakrabarty
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma, OK
| | - Adam Asch
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma, OK
| | - Ryan Nipp
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma, OK
| | - Taha Al-Juhaishi
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma, OK.
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16
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Chen XL, Zhao LM, Cai YH, Li JG, Li X. Primary B-cell non-Hodgkin lymphoma of the parotid gland: An analysis based on the SEER database. Medicine (Baltimore) 2023; 102:e33098. [PMID: 37115091 PMCID: PMC10145808 DOI: 10.1097/md.0000000000033098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 04/29/2023] Open
Abstract
Primary malignant lymphoma of the parotid gland is a rare entity. The disease is often misdiagnosed, and its survival factors remain unclear. This study included patients diagnosed with primary B-cell non-Hodgkin lymphoma of the parotid gland from 1987 to 2016 in the surveillance, epidemiology, and end results program. Univariate survival analysis was conducted using the Kaplan-Meier method, and multivariate analysis was performed using the Cox proportional hazards regression model. A competing risks regression model was applied to estimate the specific risks associated with parotid lymphoma mortality. A total of 1443 patients were identified. The overall survival of indolent primary B-cell lymphoma of the parotid gland was higher than that of aggressive lymphoma (hazard ratio 0.53, 95% confidence interval 0.44-0.64, P < .001), and older patients (≥70 years) exhibited inferior overall survival. Histological subtype and age are important prognostic factors in patients with primary B-cell non-Hodgkin lymphoma of the parotid gland.
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Affiliation(s)
- Xiang-Lei Chen
- Department of Hematology, Weifang Yidu Central Hospital, Qingzhou, P. R. China
| | - Lu-Ming Zhao
- Department of Stomatology, Weifang Yidu Central Hospital, Qingzhou, P. R. China
| | - Yuan-Hua Cai
- Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, P. R. China
| | - Jing-Gang Li
- Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, P. R. China
| | - Xin Li
- Department of Blood Transfusion Medicine, School of Medical Technology and Engineering, Fujian Medical University, Fuzhou, P. R. China
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17
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Ali EA, Sardar S, Yassin MA. Priapism in Lymphoproliferative Disorders: A Systematic Review. Hematol Oncol Stem Cell Ther 2022; 15:176-182. [PMID: 34157311 DOI: 10.1016/j.hemonc.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/20/2021] [Accepted: 05/23/2021] [Indexed: 01/14/2023] Open
Abstract
Priapism is defined as a persistent penile erection lasting more than 4 h. We searched the literature for reviews, case reports, and series for patients with lymphoproliferative disorders who developed priapism. The search involved all the lymphoproliferative disorders included in the revised 2016 World Health Organization classification of lymphoid neoplasms including chronic lymphocytic leukemia, multiple myeloma, Waldenström macroglobulinemia, and lymphomas. A total of 16 articles were found. The search included cases up to 4th January 2021. Priapism was seen most commonly as the first manifestation of lymphoproliferative disorders, rarely seen after treatment or after diagnosis.
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Affiliation(s)
- Elrazi A Ali
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Sundus Sardar
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed A Yassin
- Department of Hematology and Oncology, Hamad Medical Corporation, Doha, Qatar
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18
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Zhao J, Zhang Y, Wang W, Zhang W, Zhou DB. Clinical Characteristics, Outcomes, and Risk Factors for Patients with Diffuse Large B-Cell Lymphoma and Development of Nomogram to Identify High-Risk Patients. JOURNAL OF ONCOLOGY 2022; 2022:8395246. [PMID: 36439900 PMCID: PMC9691331 DOI: 10.1155/2022/8395246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/08/2022] [Accepted: 11/08/2022] [Indexed: 08/29/2024]
Abstract
OBJECTIVES To analyse the clinical features, outcomes, and risk factors of patients with diffuse large B-cell lymphoma (DLBCL) in China, with the aim to establish a new prognostic model based on risk factors. METHODS Clinical features and outcomes of 564 patients newly diagnosed with DLBCL from Jan 2009 to May 2017 were analyzed retrospectively. Variables were screened by LASSO regression and nomogram was constructed. RESULTS The 5-year overall survival (OS) of the cohort was 75%. The 5-year OS of patients differentiated by International Prognostic Index (IPI) score was 90% (score 0-2), 73% (score 3), and 51% (score 4-5), respectively. Age > 60, Eastern Cooperative Oncology Group (ECOG) > 1, Ann Arbor stage III-IV, bone marrow involvement, low level of albumin (ALB), and lymphatic/monocyte ratio (LMR) were independent predictors of OS. The predictive model was developed based on factors including age, bone marrow involvement, LMR, ALB, and ECOG scores. The predictive ability of the model (AUC, 0.77) was better than that of IPI (AUC, 0.74) and NCCN-IPI (AUC, 0.69). The 5-year OS of patients in the low-, intermediate-, and high-risk groups identified by the new predictive model was 89%, 70%, and 33%, respectively. CONCLUSIONS The new prediction model had better predictive performance and could better identify high-risk patients.
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Affiliation(s)
- Jinrong Zhao
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Zhang
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Wang
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Zhang
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Dao-bin Zhou
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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19
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Bliven SP, Shea L, Bal S, Goyal G, Mehta A, Narkhede M. Patterns of Utilization and Outcomes of Autologous Stem Cell Transplantation and Chimeric Antigen Receptor T-Cell Therapy in Relapsed or Refractory Diffuse Large B-cell Lymphomas with MYC and BCL2 and/or BCL6 Rearrangements. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:825-834. [PMID: 35869021 DOI: 10.1016/j.clml.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/05/2022] [Accepted: 06/24/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Patients with Diffuse Large Bcell Lymphoma (DLBCL) with MYC and BCL2 and/or BCL6 gene rearrangements [double-hit lymphoma/triple-hit lymphoma (DHL/THL)] have poor prognosis in the relapsed/refractory setting. METHODS We utilized a real-world deidentified database of DLBCL patients and report patterns of therapy utilization in relapsed/refractory DLBCL. We used log-rank test to compare real-world overall survival (rwOS) among DHL and non-DHL subgroups for CAR Tcell therapy or ASCT respectively, stratified for prior lines of therapy. RESULTS Of all 7,877 patients with DLBCL, 367 patients had DHL while 6113 had non-DHL. Second line chemotherapy was administered to 147 DHL patients and 1517 non-DHL. 1393 were excluded, including 934 with unknown DHL/THL status. Approximately 47% received salvage intent chemotherapy in the DHL subgroup, of which 19% patients eventually received ASCT, while 34% received salvage intent chemotherapy in the non-DHL/THL group with 32% receiving ASCT. DHL/THL status negatively influenced median rwOS for patients who underwent ASCT in the second-line while it was associated with numerically inferior but without statistically significant rwOS among patients that underwent CAR Tcell therapy on multivariable analysis. CONCLUSION rwOS of relapsed DHL/THL is inferior to non-DHL/THL. Fewer patients with DHL/THL were able to proceed with ASCT after salvage chemotherapy compared to non-DHL/THL. ASCT as second-line therapy for relapsed DHL/THL had worse rwOS than for non-DHL/THL, consistent with the natural history of DHL/THL. This difference was not seen for CAR Tcell therapy, which combined with promising results from clinical trials, suggests a greater role for CAR T-cell therapy in relapsed/refractory DHL.
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Affiliation(s)
| | - Lauren Shea
- Division of Hematology and Oncology, Department of Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Susan Bal
- Division of Hematology and Oncology, Department of Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Gaurav Goyal
- Division of Hematology and Oncology, Department of Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Amitkumar Mehta
- Division of Hematology and Oncology, Department of Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Mayur Narkhede
- Division of Hematology and Oncology, Department of Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL.
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Abou Elnour ES, El Sayed IET, Mohamed Abd Elbary H, Sohaib A, Amin Mohammed Atia S, El Sayed Ramadan Genena S. Biochemical and clinical impacts of miR-150 and miR-21 expression levels in diffuse large B cell lymphoma. J Immunoassay Immunochem 2022; 43:648-664. [PMID: 35915976 DOI: 10.1080/15321819.2022.2103431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Identification of biomarkers is crucial in guiding the treatment decision and improving the future outcomes of DLBCL. The aim of the current study is to detect the biochemical and clinical impacts of miR-150 and miR-21 expression levels in DLBCL. Quantification of serum miR-150 and miR-21 expression levels by real-time PCR after micro-RNA extraction and RT-PCR. At a cutoff point of 2.3 for miR-21, the sensitivity, specificity, positive predictive, and negative predictive values for diagnosis of DLBCL were 98%, 90%, 90.7%, and 97.8%, respectively. At cut-off point (≤19.12) the sensitivity, specificity, the positive predictive and negative predictive values of miR-21 to discriminate stage IV vs stage II DLBCL patients were 68.42%, 80%, 86.7%%,and 57.1%, respectively. Serum miR-150 and serum miR-21 can be used as diagnostic markers for DLBCL patients, but miR-21 is more sensitive than miR-150. Serum miR-21 can be used as prognostic marker for DLBCL patients. It was more sensitive and more specific than miR-150.
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Affiliation(s)
- Elsayed Saber Abou Elnour
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine - Menoufia University, Shibin Al Kawm, Egypt
| | | | | | - Ahmed Sohaib
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine - Menoufia University, Shibin Al Kawm, Egypt
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Blue B. Socioeconomic and Racial Disparity in Chimeric antigen receptor T cell (CART)Therapy Access. Transplant Cell Ther 2022; 28:345-346. [DOI: 10.1016/j.jtct.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Thakkar A, Abreu M, Pradhan K, Sica RA, Shastri A, Kornblum N, Shah N, Mantzaris I, Gritsman K, Feldman E, Elkind R, Green-Lorenzen S, Verma A, Braunschweig I, Goldfinger M. Efficacy and safety of CAR-T cell therapy in minorities. Bone Marrow Transplant 2022; 57:1187-1190. [PMID: 35484206 DOI: 10.1038/s41409-022-01670-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Astha Thakkar
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA
| | - Michelly Abreu
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA
| | - Kith Pradhan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - R Alejandro Sica
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA
| | - Aditi Shastri
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA
| | - Noah Kornblum
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA
| | - Nishi Shah
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA
| | - Ioannis Mantzaris
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA
| | - Kira Gritsman
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA
| | - Eric Feldman
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA
| | - Richard Elkind
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA
| | | | - Amit Verma
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA
| | - Ira Braunschweig
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA.
| | - Mendel Goldfinger
- Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Montefiore Medical Center, Bronx, New York, NY, USA.
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Vaughn JL, Gundepalli SG, Epperla N. Racial differences in the survival of mantle cell lymphoma patients in the United States. Hematol Oncol 2022; 40:479-481. [PMID: 35245968 DOI: 10.1002/hon.2984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
N/A This article is protected by copyright. All rights reserved.
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Affiliation(s)
- John L Vaughn
- Division of Bone Marrow Transplant, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
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Pre-treatment neutrophil-lymphocyte and monocyte-lymphocyte ratios give clues about response, survival, and recurrence in diffuse large B-cell lymphoma. ARCHIVE OF ONCOLOGY 2022. [DOI: 10.2298/aoo201122003d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Diffuse large B cell lymphoma is a heterogeneous tumor group
consisting of large and transformed B cells that makeup 30-40% of all
non-Hodgkin lymphoma. Numerous studies point out that initial parameters and
post-treatment responses can be used as prognostic factors. We aimed to
examine the relationship between diagnosis, clinical and laboratory
parameters, treatment response and survival using neutrophil-lymphocyte and
monocyte-lymphocyte ratios. Methods: A total of 80 patients, followed in our
hematology clinic between January 2009-2019, were included in the study and
were analyzed retrospectively. Results: The median value of neutrophil-
lymphocyte ratio was 3.5 (0.3-50.2) and of monocyte/lymphocyte ratio was 0.3
(0.1-4.8). In the group with neutrophil-lymphocyte ratio ? 3.5 response
rates was significantly lower and exitus rate and the bulky mass presence
were significantly higher compared to the group with > 3.5 values (p <
0.05). In the group with monocyte-lymphocyte ratio ? 0.30, the exitus rate
was significantly higher compared to group with < 0.30 values (p < 0.05).
Conclusion: A statistically significant bulky mass presence was demonstrated
in the population above the neutrophil-lymphocyte ratio and
monocyte-lymphocyte ratio cut off. Although not considered to be sufficient
alone, these parameters could be used as prognostic factors in combination
with current scoring systems.
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Bakirtas M, Yiğenoğlu T, Başci S, Ulu B, Yaman S, Çakar M, Dal M, Altuntaş F. Febrile neutropenia risk factors in actively treated diffuse large B-cell lymphoma patients. IRAQI JOURNAL OF HEMATOLOGY 2022. [DOI: 10.4103/ijh.ijh_37_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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26
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Gogia A, Nair S, Arora S, Kumar L, Sharma A, Gupta R, Biswas A, Mallick S. Impact of Cell-of-Origin on Outcome of Patients With Diffuse Large B-Cell Lymphoma Treated With Uniform R-CHOP Protocol: A Single-Center Retrospective Analysis From North India. Front Oncol 2021; 11:770747. [PMID: 34926277 PMCID: PMC8675100 DOI: 10.3389/fonc.2021.770747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 11/10/2021] [Indexed: 12/21/2022] Open
Abstract
Introduction There is a scarcity of data from India on the impact of cell of origin (COO) on outcomes of diffuse large B-cell lymphoma (DLBCL). This study was conducted to evaluate the impact of COO on outcomes of DLBCL patients treated with uniform rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (RCHOP) protocol. Materials and Methods This retrospective analysis included patients who received uniform RCHOP chemoimmunotherapy during the study period (2014–2020) at the Department of Medical Oncology at All India Institute of Medical Sciences (AIIMS), New Delhi, India. The patients were classified as germinal center B-cell like (GCB) or activated B-cell (ABC) type using the Hans classification. Results Four hundred seventeen patients with median age of 48 years (range, 18–76) and a male-female ratio of 2:1 were included in the analysis. B symptoms and bulky disease were seen in 42.9% and 35.5%. Extranodal involvement was seen in 50.8% of cases. ECOG performance status (0-2) was present in 65%, and 51% presented with advanced disease. GCB subtype was seen in 43%, and 47% were ABC type. Low- and intermediate-risk international prognostic index (IPI) score was seen in 76% of cases. The overall response rate to RCHOP was 85.8%, including a complete response rate of 74.8%. After a median follow-up of 30 months, the 3-year event-free survival (EFS) and overall survival (OS) were 80% and 88%, respectively. The presence of B symptoms and poor ECOG performance status (3-4) was associated with inferior CR rate. Low albumin (p < 0.001), age >60 years (p = 0.001), bulky disease (p < 0.001), and extranodal involvement (p = 0.001) were associated with inferior EFS, whereas a high IPI risk score was associated with an inferior OS (p < 0.001). EFS and OS were not significantly different between the GCB and ABC subtypes. Grade III/IV anemia, neutropenia, and thrombocytopenia were seen in 7.6%, 13.6%, and 2.7% of patients, respectively. Febrile neutropenia was seen in 8.9% of patients, and there were four treatment-related deaths. Conclusions Cell of origin for DLBCL has no impact on CR, EFS, and OS if patients are appropriately treated with standard doses and frequency of RCHOP. RCHOP is well tolerated in our patients, and results are comparable with the Western data.
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Affiliation(s)
- Ajay Gogia
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
- *Correspondence: Ajay Gogia,
| | - Sukesh Nair
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Shalabh Arora
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Lalit Kumar
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Ritu Gupta
- Department of Laboratory Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Ahitagni Biswas
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Saumyaranjan Mallick
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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Racial and ethnic survival disparities in patients with haematological malignancies in the USA: time to stop ignoring the numbers. THE LANCET HAEMATOLOGY 2021; 8:e947-e954. [DOI: 10.1016/s2352-3026(21)00303-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 09/05/2021] [Accepted: 09/21/2021] [Indexed: 12/17/2022]
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Hu B, Boselli D, Pye LM, Chen T, Bose R, Symanowski JT, Blackley K, Moyo TK, Jacobs R, Park SI, Soni A, Avalos BR, Copelan EA, Raghavan D, Ghosh N. Equal access to care and nurse navigation leads to equitable outcomes for minorities with aggressive large B-cell lymphoma. Cancer 2021; 127:3991-3997. [PMID: 34289094 DOI: 10.1002/cncr.33779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/04/2021] [Accepted: 06/10/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Aggressive large B-cell lymphomas (LBCLs) are curable, but previous studies have shown inferior outcomes in minorities. Nurse navigation programs can improve patient outcomes by providing patient support. This study presents the outcomes of White and minority patients with aggressive LBCL at an institution with an active nurse navigation program. METHODS The authors prospectively collected baseline characteristics, treatment regimens, and outcome data for patients with aggressive LBCL. Navigation encounters were characterized as low or high intensity. Overall survival (OS) and progression-free survival (PFS) were calculated with Kaplan-Meier methods. Baseline characteristics were compared with Fisher exact tests. RESULTS Two hundred four consecutive patients (47 minority patients and 157 White patients) were included. Results were presented as minorities versus Whites. There were no differences in prognostic scores (Revised International Prognostic Index score of 3-5, 43% vs 47%; P = .50), frontline chemotherapy (98% vs 96%; P = .68), or the incidence of relapsed/refractory disease (40% vs 38%; P = .74). For relapsed/refractory LBCL, similar proportions of patients underwent hematopoietic stem cell transplantation (32% vs 29%; P > .99) or chimeric antigen receptor T-cell therapy (16% vs 19%; P > .99). Enrollment in clinical trials was comparable (17% vs 14%; P = .64). More than 85% received nurse navigation, but minorities had higher intensity navigation encounters (42% vs 21%; P = .01). The 2-year OS rates were 81% and 76% for minorities and Whites, respectively (P = .27); the 2-year PFS rates were 62% and 65%, respectively (P = .78). CONCLUSIONS This study shows similar survival between Whites and minorities with aggressive LBCL, which was likely due to equal access to guideline-concordant therapy. Minorities received higher intensity navigation encounters, which may have helped them to overcome socioeconomic disadvantages.
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Affiliation(s)
- Bei Hu
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Danielle Boselli
- Department of Biostatistics, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Lisa M Pye
- Department of Patient Navigation, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Tommy Chen
- Department of Biostatistics, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Rupali Bose
- Department of Biostatistics, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - James T Symanowski
- Department of Biostatistics, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Kris Blackley
- Department of Patient Navigation, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Tamara K Moyo
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Ryan Jacobs
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Steven I Park
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Amy Soni
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Belinda R Avalos
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Edward A Copelan
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Derek Raghavan
- Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Nilanjan Ghosh
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
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Outcomes of Richter's transformation of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL): an analysis of the SEER database. Ann Hematol 2021; 100:2513-2519. [PMID: 34279675 DOI: 10.1007/s00277-021-04603-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
Richter's transformation (RT) is a rare complication arising in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and is associated with an overall dismal outcome. The rarity of this entity poses many challenges in understanding its biology and outcomes seen and the optimal treatment approach. We utilized the SEER (Surveillance, Epidemiology and End Results) database to identify patients diagnosed with CLL/SLL between 2000 and 2016 and subsequently had a diagnosis of diffuse large B-cell lymphoma (DLBCL) or Hodgkin lymphoma (HL), thus capturing those who experienced an RT event. We compared the outcomes of those patients to those of patients in the database diagnosed with DLBCL without a preceding CLL/SLL diagnosis. We identified 530 patients who developed RT out of 74,116 patients diagnosed with CLL/SLL in the specified period. The median age at RT diagnosis was 66 years, and the median time from CLL/SLL diagnosis to RT development was roughly 4 years. Patients with RT had a dismal outcome with median overall survival of 10 months. We identified advanced Ann Arbor stage (III/IV) and prior treatment for CLL as predictors of worse outcome in patients with RT. Our study represents the largest dataset of patients with CLL/SLL and RT and adds to the existing literature indicating the poor outcomes for those patients.
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Hwang J, Suh C, Kim K, Kim H, Kim AI, Craig JW, Chen KX, Roberson J, Guenette JP, Huang RY. The Incidence and Treatment Response of Double Expression of MYC and BCL2 in Patients with Diffuse Large B-Cell Lymphoma: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:3369. [PMID: 34282799 PMCID: PMC8268769 DOI: 10.3390/cancers13133369] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/02/2021] [Accepted: 07/02/2021] [Indexed: 12/15/2022] Open
Abstract
MYC/BCL2 protein co-expression (i.e., double expressor) has been shown to be a negative predictor of outcome in diffuse large B-cell lymphoma (DLBCL). We aimed to establish the incidence of double expressor status in patients with de novo DLBCL and identify the predictive value of this biomarker on treatment response through systematic review and meta-analysis. PubMed and Embase were searched for studies published through December 2019 that reported proportions of double expressor DLBCL. The pooled proportions of MYC and BCL2 expression, both alone and in combination, were computed using the inverse variance method for calculating weights and by the DerSimonian-Laird method. The pooled odds ratios (ORs) of complete remission (CR) rate were calculated, and meta-regression analysis was conducted to explore heterogeneity. Forty-one studies (7054 patients) were included. The pooled incidence of double expressor status in DLBCL was 23% (95% confidence interval [CI], 20-26%), with an adjusted estimate of 31% (95% CI, 27-36%). Neither MYC/BCL2 protein cutoff values, race, mean, or median age of included patients, or overall study quality was a significant factor of heterogeneity (p ≥ 0.20). Cases without double expressor status demonstrated a higher probability of CR to rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone treatment (OR, 2.69; 95% CI, 1.55-4.67). Our results reaffirm the predictive power of this important biomarker.
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Affiliation(s)
- Jisun Hwang
- Department of Radiology, Dongtan Sacred Heart Hospital, Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si 18450, Gyeonggi-do, Korea;
| | - Chonghyun Suh
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 33, Seoul 05505, Korea; (K.K.); (H.K.)
| | - Kyungwon Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 33, Seoul 05505, Korea; (K.K.); (H.K.)
| | - Hosung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 33, Seoul 05505, Korea; (K.K.); (H.K.)
| | - Austin I. Kim
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA;
| | - Jeffrey W. Craig
- Centre for Lymphoid Cancer, British Columbia Cancer, Vancouver, BC V5Z 4E6, Canada;
| | - Ke Xun Chen
- Division of Neuroradiology, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; (K.X.C.); (J.R.); (J.P.G.); (R.Y.H.)
| | - Joel Roberson
- Division of Neuroradiology, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; (K.X.C.); (J.R.); (J.P.G.); (R.Y.H.)
| | - Jeffrey P. Guenette
- Division of Neuroradiology, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; (K.X.C.); (J.R.); (J.P.G.); (R.Y.H.)
| | - Raymond Y. Huang
- Division of Neuroradiology, Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; (K.X.C.); (J.R.); (J.P.G.); (R.Y.H.)
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Abdel-Razeq H, Ma’koseh M, Abdel-Razeq R, Amarin R, Abufara A, Mansour R, Manasrah M, Al-Rwashdeh M, Bater R. The Application of the Lymphoma International Prognostic Index to Predict Venous Thromboembolic Events in Diffuse Large B-Cell Lymphoma Patients. Front Oncol 2021; 11:677776. [PMID: 34123847 PMCID: PMC8195619 DOI: 10.3389/fonc.2021.677776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/04/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Venous thromboembolic events (VTE) are commonly encountered in patients with lymphoma. Several risk assessments models (RAM) had attempted to identify higher risk patients with varying success. The International Prognostic Index (IPI) is a clinicopathological tool developed to help predict both response to treatment and prognosis of patients with diffuse large B-cell lymphoma (DLBCL). OBJECTIVE In this study, we utilize the IPI index to identify group of patients with DLBCL at higher risk for VTE. PATIENTS/METHODS Patients with pathologically-confirmed diagnosis of DLBCL and with image-confirmed VTE, treated and followed at our institution were included. Rates of VTE was calculated for each risk category. RESULTS A total of 373 patients, median age 49 (range: 18-90) years were included. VTE were reported in 56 (15.0%) patients; 51 (91.1%) had active disease while 29 (51.8%) were ambulatory at time of VTE diagnosis. VTE rates were particularly high among patients with poor performance status (26.2%, P=0.028) and high LDH (19.0%, P=0.023). Applying the age-adjusted IPI separated patients into two risk categories; VTE were diagnosed in 9.7% in patients with "low and low-intermediate" scores compared to 19.8% in patients with "high and high-intermediate" scores, P=0.020. CONCLUSIONS The original IPI and its modified versions, routinely used at diagnosis as a prognostic and predictive tool for patients with DLBCL, can also be utilized to define high risk patients for VTE; the risk of whom might be high enough to recommend thromboprophylaxis even in the ambulatory settings. More work is needed to refine and improve currently available RAMs.
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Affiliation(s)
- Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
- School of Medicine, University of Jordan, Amman, Jordan
| | - Mohammad Ma’koseh
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | | | - Rula Amarin
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Alaa Abufara
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Razan Mansour
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Mohammad Manasrah
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | | | - Rayan Bater
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
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Dance KV, Imbody CB, Chen L, McNeill L, Payne JB, Flowers CR. Perceptions of clinical care and research among African-American patients with lymphoma. Leuk Lymphoma 2021; 62:1860-1868. [PMID: 33645400 DOI: 10.1080/10428194.2021.1892092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Across lymphoma subtypes, African Americans experience disparities in clinical trial enrollment and outcomes. Understanding the needs of this population can aid addressing these disparities. Semi-structured interviews were conducted with 14 self-identified Black/African-American lymphoma patients to determine their perceptions and attitudes about aspects of treatment and research. Constant-comparative methods identified themes including trust in medical staff, lack of diagnosis information, interest in research, research priorities, and potentially unaddressed emotional needs. Patients trusted their doctors and desired more diagnosis information. Participants often did not consider the emotions surrounding their diagnoses and concentrated on positive attitudes during treatment. Most participants were interested in clinical trials to help future lymphoma patients. Participants suggested a range of future research topics emphasizing lymphoma etiology. Building on trusting doctor-patient relationships, expanding clinical trials information, addressing emotional needs, and aligning research objectives with patient concerns are potential strategies for increasing clinical trial enrollment among Black lymphoma patients.
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Affiliation(s)
- Kaylin V Dance
- Winship Cancer Institute, Emory University, Atlanta, GE, USA
| | - Conner B Imbody
- Winship Cancer Institute, Emory University, Atlanta, GE, USA.,Department of Behavioral Science and Health Education, Rollins School of Public Health, Atlanta, GE, USA
| | - Lillian Chen
- Winship Cancer Institute, Emory University, Atlanta, GE, USA
| | - Lorna McNeill
- Winship Cancer Institute, Emory University, Atlanta, GE, USA.,Department of Behavioral Science and Health Education, Rollins School of Public Health, Atlanta, GE, USA.,Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jackelyn B Payne
- Winship Cancer Institute, Emory University, Atlanta, GE, USA.,Department of Behavioral Science and Health Education, Rollins School of Public Health, Atlanta, GE, USA.,Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| | - Christopher R Flowers
- Winship Cancer Institute, Emory University, Atlanta, GE, USA.,Department of Behavioral Science and Health Education, Rollins School of Public Health, Atlanta, GE, USA.,Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Smith-Graziani D, Flowers CR. Understanding and Addressing Disparities in Patients With Hematologic Malignancies: Approaches for Clinicians. Am Soc Clin Oncol Educ Book 2021; 41:1-7. [PMID: 33793311 DOI: 10.1200/edbk_320079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Approximately 185,840 individuals will be diagnosed with hematologic malignancies in the United States in 2020. Disparities in disease incidence, prevalence, burden, mortality, and survivorship have been identified among this patient population. Contributing factors include genetic ancestry, race/ethnicity, sex, socioeconomic status, and geographic region. Historically, these inequities have been understudied. Addressing these disparities requires a systems-level approach, improving access to care and reducing biases in the clinical setting. Additional research is needed to construct comprehensive, multilevel models to explore systematic observational studies and perform strategic intervention trials to overcome these disparities.
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Affiliation(s)
| | - Christopher R Flowers
- Department of Lymphoma/Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer, Houston, TX
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Khullar K, Plascak JJ, Drachtman R, Cole PD, Parikh RR. Associations between race and survival in pediatric patients with diffuse large B-cell lymphoma. Cancer Med 2021; 10:1327-1334. [PMID: 33503323 PMCID: PMC7926019 DOI: 10.1002/cam4.3736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/30/2020] [Accepted: 01/01/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The purpose of this study was to examine the factors associated with disparities in overall survival (OS) by race in pediatric diffuse large B-cell lymphoma (DLBCL) patients. METHODS We evaluated clinical features and survival among patients ≤21 years of age diagnosed with stage I-IV DLBCL from 2004 to 2014 from the National Cancer Database (NCDB) using a multivariable Cox proportional hazards model. RESULTS Among 1386 pediatric patients with DLBCL, 1023 patients met eligibility criteria. In unadjusted analysis, Black patients had a significantly higher overall death rate than White patients (HRBlack vs. White 1.51; 95% CI: 1.02-2.23, p = 0.041). The survival disparity did not remain significant in adjusted analysis, though controlling for covariates had little effect on the magnitude of the disparity (HR 1.46; 95% CI 0.93-2.31, p = 0.103). In adjusted models, presence of B symptoms, receipt of chemotherapy, stage of disease, and Other insurance were significantly associated with OS. Specifically, patients with B symptoms and those with Other insurance were more likely to die than those without B symptoms or private insurance, respectively (HR 1.75; 95% CI 1.22-2.50, p = 0.002) and (HR 2.56; 95% CI, 1.39-4.73, p = 0.0027), patients who did not receive chemotherapy were three times more likely to die than those who received chemotherapy (HR 3.10; CI 1.80-5.35, p < 0.001), and patients who presented with earlier stage disease were less likely to die from their disease than those with stage IV disease (stages I-III HR 0.34, CI 0.18-0.64, p < 0.001; HR 0.50, CI 0.30-0.82, p = 0.006, HR 0.72, CI 0.43-1.13, p = 0.152, respectively). CONCLUSIONS Our results suggest that racial disparities in survival may be mediated by clinical and treatment parameters.
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Affiliation(s)
- Karishma Khullar
- Department of Radiation OncologyRutgers Cancer Institute of New JerseyNew BrunswickNJUSA
| | - Jesse J. Plascak
- Department of Biostatistics and EpidemiologyRutgers School of Public HealthPiscatawayNJUSA
| | - Richard Drachtman
- Section of Pediatric Hematology and OncologyRutgers Cancer Institute of New JerseyNew BrunswickNJUSA
| | - Peter D. Cole
- Section of Pediatric Hematology and OncologyRutgers Cancer Institute of New JerseyNew BrunswickNJUSA
| | - Rahul R. Parikh
- Department of Radiation OncologyRutgers Cancer Institute of New JerseyNew BrunswickNJUSA
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Bakhshi TJ, Georgel PT. Genetic and epigenetic determinants of diffuse large B-cell lymphoma. Blood Cancer J 2020; 10:123. [PMID: 33277464 PMCID: PMC7718920 DOI: 10.1038/s41408-020-00389-w] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/25/2020] [Accepted: 10/28/2020] [Indexed: 12/12/2022] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common type of lymphoma and is notorious for its heterogeneity, aggressive nature, and the frequent development of resistance and/or relapse after treatment with standard chemotherapy. To address these problems, a strong emphasis has been placed on researching the molecular origins and mechanisms of DLBCL to develop effective treatments. One of the major insights produced by such research is that DLBCL almost always stems from genetic damage that occurs during the germinal center (GC) reaction, which is required for the production of high-affinity antibodies. Indeed, there is significant overlap between the mechanisms that govern the GC reaction and those that drive the progression of DLBCL. A second important insight is that some of the most frequent genetic mutations that occur in DLBCL are those related to chromatin and epigenetics, especially those related to proteins that “write” histone post-translational modifications (PTMs). Mutation or deletion of these epigenetic writers often renders cells unable to epigenetically “switch on” critical gene sets that are required to exit the GC reaction, differentiate, repair DNA, and other essential cellular functions. Failure to activate these genes locks cells into a genotoxic state that is conducive to oncogenesis and/or relapse.
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Affiliation(s)
- Tanner J Bakhshi
- Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, 25755, USA
| | - Philippe T Georgel
- Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, 25755, USA. .,Department of Biological Sciences, Cell Differentiation and Development Center, Byrd Biotechnology Science Center, Marshall University, Huntington, WV, 25755, USA.
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Başcı S, Bakırtaş M, Yiğenoğlu TN, Uncu Ulu B, Batgi H, Yıldız J, Dal MS, Kızıl Çakar M, Altuntaş F. The Outcome of Diffuse Large B Cell Lymphoma Patients in Adolescent and Young Adult Age Group. J Adolesc Young Adult Oncol 2020; 10:483-487. [PMID: 33237829 DOI: 10.1089/jayao.2020.0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: In the literature, substantial differences have been reported regarding incidence and outcomes for the pediatric and adult groups with non-Hodgkin's lymphoma (NHL). Diffuse large B cell lymphoma (DLBCL) is the most common NHL subtype, and its outcome in adolescents and young adults (AYA) has not been widely investigated. This study aims at reporting our experience on the outcome of DLBCL in the AYA group. Methods: One hundred twenty DLBCL patients, 40 AYA patients, and 1:2 matched 80 control non-AYA patients were diagnosed and followed up at our center included. Results: In both groups, the median progression-free survival (PFS) and overall survival (OS) were not reached, without any difference between groups (p = 0.7, p = 0.7, respectively). The median follow-up time was 28 (range 1-133) months in all patients. In both groups, international prognostic index scores and early relapse were associated with worse PFS and OS, but in the non-AYA group, the immunohistologic type was, in fact, related to worse outcomes. Conclusion: DLBCL in AYA is a predominantly overlooked subject, due to the rarity of the disease. The outcome of DLBCL in this age group is not encouraging, which not only needs to be further investigated, but novel approaches must also be developed.
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Affiliation(s)
- Semih Başcı
- Department of Hematology and Bone Marrow Transplantation Center, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Mehmet Bakırtaş
- Department of Hematology and Bone Marrow Transplantation Center, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Tuğçe Nur Yiğenoğlu
- Department of Hematology and Bone Marrow Transplantation Center, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Bahar Uncu Ulu
- Department of Hematology and Bone Marrow Transplantation Center, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Hikmetullah Batgi
- Department of Hematology and Bone Marrow Transplantation Center, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Jale Yıldız
- Department of Hematology and Bone Marrow Transplantation Center, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Mehmet Sinan Dal
- Department of Hematology and Bone Marrow Transplantation Center, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Merih Kızıl Çakar
- Department of Hematology and Bone Marrow Transplantation Center, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Fevzi Altuntaş
- Department of Hematology and Bone Marrow Transplantation Center, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
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Tiu A, Jorge V, Moussa P, Djibo DA, Gupta S, Alpdogan O, Dourado C. Survival Disparities of Diffuse Large B-Cell Lymphoma in a Community-Based Inner-City Cancer Center. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 21:205-215. [PMID: 33139233 DOI: 10.1016/j.clml.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/04/2020] [Accepted: 10/04/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Diffuse large B-cell lymphoma (DLBCL) comprises approximately 30% of all non-Hodgkin lymphomas. Multiple studies have demonstrated race-based disparities in survival among patients with DLBCL across all stages of disease, in the era both before and after rituximab. The etiology for the racial disparities in survival among patients with DLBCL is still unknown. Moreover, the Revised International Prognostic Index (R-IPI), a tool that predicts the DLBCL patients' outcome, has not yet been validated in African Americans (AA). PATIENTS AND METHODS We conducted a cohort study of patients diagnosed with DLBCL from January 1, 2007, to December 31, 2017, from our tumor registry in a single community-based inner-city cancer center. We abstracted demographic, clinical, histopathologic, treatment, and R-IPI variables. A total of 181 patients (47.5%) with biopsy-proven DLBCL were included in the retrospective analysis. The median age was 65 years, 47% were men, 41% were AA, and 44% were white. RESULTS The AA group had a younger median age, higher lactate dehydrogenase levels, higher frequency of B symptoms, and higher HIV infection than the non-AA group. The AA group had significantly decreased median overall survival than the non-AA group (15.7 months; 95% confidence interval, 10.3 to 23.9, vs. 93.6 months; 95% confidence interval, 61.5 to 142.6, respectively; P < .001). The survival disparities persisted after excluding patients with HIV and who did not receive chemotherapy. In addition, AA race predicts a reduced survival by univariate and multivariate analysis. CONCLUSION AA with DLBCL may have a poorer prognosis than the non-AA population. Further studies should investigate the biology of DLBCL in the AA population.
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Affiliation(s)
- Andrew Tiu
- Department of Medicine, Einstein Medical Center, Philadelphia, PA.
| | - Vinicius Jorge
- Division of Hematology and Medical Oncology, Einstein Medical Center, Philadelphia, PA
| | - Peter Moussa
- Department of Medicine, Einstein Medical Center, Philadelphia, PA
| | - Djeneba Audrey Djibo
- Division of Research, Department of Medicine, Einstein Medical Center, Philadelphia, PA
| | - Sorab Gupta
- Division of Hematology and Medical Oncology, Einstein Medical Center, Philadelphia, PA
| | - Onder Alpdogan
- Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Claudia Dourado
- Division of Hematology and Medical Oncology, Einstein Medical Center, Philadelphia, PA
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Blansky D, Fazzari M, Mantzaris I, Rohan T, Hosgood HD. Racial and ethnic differences in diffuse large B-cell lymphoma survival among an underserved, urban population. Leuk Lymphoma 2020; 62:581-589. [PMID: 33112182 DOI: 10.1080/10428194.2020.1839656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Racial/ethnic differences in diffuse large B-cell lymphoma (DLBCL) survival have focused on non-Hispanic Whites (NHW) and non-Hispanic Blacks (NHB), often excluding Hispanics/Latinos. To further assess these racial/ethnic survival differences, we identified incident DLBCL cases diagnosed between 2005 and 2016 (n = 404; NHW = 136, NHB = 106, Hispanic/Latino = 162) at Montefiore Medical Center (Bronx, NY). All-cause mortality survival curves were assessed by the Kaplan-Meier method and log-rank test. Cox proportional hazards regression assessed the association between demographic/clinical factors and all-cause mortality. Hispanic/Latino patients experienced 52% lower risk of mortality compared to NHWs (HR = 0.48, 95%CI = 0.28-0.83), after adjusting for clinical prognostic factors. This reduced risk experienced by Hispanics/Latinos was similarly observed by age at diagnosis (≤60 years, >60 years), stage (I/II, III/IV), and receipt of chemotherapy. NHBs and NHWs experienced similar risk of mortality (HR = 0.85, 95%CI = 0.52-1.40). Overall, among DLBCL patients, Hispanics/Latinos had improved survival compared to NHWs. Additional research should seek to identify the drivers of this survival benefit.
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Affiliation(s)
- Deanna Blansky
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Melissa Fazzari
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Thomas Rohan
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - H Dean Hosgood
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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Serin I, Ulusoy A, Onar MI, Dogu MH. Recurrence of lymphoma with isolated pericardial mass: a case report. J Med Case Rep 2020; 14:175. [PMID: 33008468 PMCID: PMC7532119 DOI: 10.1186/s13256-020-02508-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/19/2020] [Indexed: 11/10/2022] Open
Abstract
Background Diffuse large B-cell lymphoma is the most common subtype of non-Hodgkin lymphoma and may occur with lymph node and/or extranodal involvement. Recurrence in patients with diffuse large B-cell lymphoma usually occurs within the first few years after treatment and may occur in a different area outside the initial localization. Case presentation A female Turkish patient who was diagnosed with nodular sclerosing Hodgkin lymphoma through lymphadenopathy examination reached remission after chemotherapy and radiotherapy. In the 11th year of follow-up and at the age of 45, newly developed multiple lymphadenopathies were diagnosed with a pathological result of diffuse large B-cell lymphoma in her advanced examination. Due to massive splenomegaly and cystic necrotic splenic residues, splenectomy was performed after eight cycles of a first-line chemotherapy regimen and two cycles of high-dose methotrexate treatment for central nervous system prophylaxis. A pericardial mass (maximum standardized uptake value 34.8), which was not present at the time of diagnosis and interim evaluation of positron emission tomography/computed tomography, was detected through chest pain in the third month after the last screening, although a complete response had been obtained. Pathological examination of the pericardial area revealed the pathological result was a recurrence. Conclusions Patients with diffuse large B-cell lymphoma have an aggressive clinical course, but cardiac involvement is very rare. In our patient’s case, pericardial involvement was observed after treatment and scanning revealed that recurrence took place in an area different from the pericardium. Cooperation of clinicians and pathologists and rapid evaluation are very important in cases of diffuse large B-cell lymphoma relapse. Although a tumoral invasion of the pericardium mostly suggests secondary malignancies, it should be kept in mind that recurrence of lymphoma is also possible.
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Affiliation(s)
- Istemi Serin
- Department of Hematology Istanbul, University of Health Sciences, Istanbul Training and Research Hospital, 34098, Istanbul, Turkey.
| | - Avni Ulusoy
- Department of Internal Medicine, University of Health Sciences, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Mediha Irem Onar
- Department of Internal Medicine, University of Health Sciences, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Hilmi Dogu
- Department of Hematology Istanbul, University of Health Sciences, Istanbul Training and Research Hospital, 34098, Istanbul, Turkey
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Blansky D, Mantzaris I, Rohan T, Hosgood HD. Influence of Rurality, Race, and Ethnicity on Non-Hodgkin Lymphoma Incidence. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2020; 20:668-676.e5. [PMID: 32605898 PMCID: PMC7976043 DOI: 10.1016/j.clml.2020.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Exposure to lymphomagens vary by geography. The extent to which these contribute to racial and ethnic disparities in non-Hodgkin lymphoma (NHL) incidence is not well understood. We sought to evaluate the association between urban-rural status and racial and ethnic disparities in the 3 major NHL subtypes: diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), and chronic lymphocytic leukemia (CLL). PATIENTS AND METHODS We used data on NHL incidence from 21 Surveillance, Epidemiology, and End Results (SEER) population-based registries for the period 2000 to 2016. Population characteristics were compared by NHL subtype and urban-rural status, using rural-urban continuum codes from the US Department of Agriculture. Incidence rate ratios were calculated, and Poisson regression was used to assess the association between incidence and rurality. RESULTS A total of 136,197 DLBCL, 70,882 FL, and 120,319 CLL incident cases aged ≥ 20 years were reported. The majority of DLBCL patients were non-Hispanic white (73.5%), with 11.9% Hispanic and 7.3% non-Hispanic black, with a similar distribution observed in FL and CLL. Adjusting for age, sex, and family poverty, we found increased DLBCL incidence among Hispanics in increasingly urban areas compared to rural areas (rural incidence rate ratio [IRR] = 1.00; nonmetropolitan urban IRR = 1.32, 95% CI 1.16, 1.51; metropolitan urban IRR = 1.55, 95% CI 1.36, 1.76). Among non-Hispanic blacks, urban areas, relative to rural areas, were associated with increased CLL incidence (IRR = 1.48; 95% CI 1.27, 1.72). CONCLUSION Urban-rural incidence patterns suggest that environmental exposures in urban areas associated with DLBCL and CLL pathogenesis may disproportionately affect Hispanics and non-Hispanic blacks.
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Affiliation(s)
- Deanna Blansky
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.
| | - Ioannis Mantzaris
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Thomas Rohan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - H Dean Hosgood
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
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Lee MJ, Koff JL, Switchenko JM, Jhaney CI, Harkins RA, Patel SP, Dave SS, Flowers CR. Genome-defined African ancestry is associated with distinct mutations and worse survival in patients with diffuse large B-cell lymphoma. Cancer 2020; 126:3493-3503. [PMID: 32469082 DOI: 10.1002/cncr.32866] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/17/2020] [Accepted: 03/04/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Significant racial differences have been observed in the incidence and clinical outcomes of diffuse large B-cell lymphoma (DLBCL) in the United States, but to the authors' knowledge it remains unclear whether genomic differences contribute to these disparities. METHODS To understand the influences of genetic ancestry on tumor genomic alterations, the authors estimated the genetic ancestry of 1001 previously described patients with DLBCL using unsupervised model-based Admixture global ancestry analysis applied to exome sequencing data and examined the mutational profile of 150 DLBCL driver genes in tumors obtained from this cohort. RESULTS Global ancestry prediction identified 619 patients with >90% European ancestry, 81 patients with >90% African ancestry, and 50 patients with >90% Asian ancestry. Compared with patients with DLBCL with European ancestry, patients with African ancestry were aged >10 years younger at the time of diagnosis and were more likely to present with B symptoms, elevated serum lactate dehydrogenase, extranodal disease, and advanced stage disease. Patients with African ancestry demonstrated worse overall survival compared with patients with European ancestry (median, 4.9 years vs 8.8 years; P = .04). Recurrent mutations of MLL2 (KMT2D), HIST1H1E, MYD88, BCL2, and PIM1 were found across all ancestry groups, suggesting shared mechanisms underlying tumor biology. The authors also identified 6 DLBCL driver genes that were more commonly mutated in patients with African ancestry compared with patients with European ancestry: ATM (21.0% vs 7.75%; P < .001), MGA (19.7% vs 5.33%; P < .001), SETD2 (17.3% vs 5.17%; P < .001), TET2 (12.3% vs 5.82%; P = .029), MLL3 (KMT2C) (11.1% vs 4.36%; P = .013), and DNMT3A (11.1% vs 4.52%; P = .016). CONCLUSIONS Distinct prevalence and patterns of mutation highlight an important difference in the mutational landscapes of DLBCL arising in different ancestry groups. To the authors' knowledge, the results of the current study provide the first-ever characterization of genetic alterations among patients with African descent who are diagnosed with DLBCL.
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Affiliation(s)
- Michelle J Lee
- Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Jean L Koff
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA
| | - C Ileen Jhaney
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | | | - Sharvil P Patel
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Sandeep S Dave
- Center for Genomic and Computational Biology, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Christopher R Flowers
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Shree T, Li Q, Glaser SL, Brunson A, Maecker HT, Haile RW, Levy R, Keegan THM. Impaired Immune Health in Survivors of Diffuse Large B-Cell Lymphoma. J Clin Oncol 2020; 38:1664-1675. [PMID: 32083991 PMCID: PMC7238489 DOI: 10.1200/jco.19.01937] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2019] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Therapeutic advances for diffuse large B-cell lymphoma (DLBCL) have led to an increasing number of survivors. Both DLBCL and its treatments perturb the immune system, yet little is known about immune health during extended survivorship. METHODS In this retrospective cohort study, we compared 21,690 survivors of DLBCL from the California Cancer Registry (CCR) to survivors of breast, prostate, head and neck, and melanoma cancers. We linked their CCR records to a statewide database documenting hospital, emergency room, and ambulatory surgery visits and investigated the incidence of autoimmune conditions, immune deficiencies, and infections 1-10 years after cancer diagnosis. RESULTS We found elevated incidence rate ratios (IRRs) for many immune-related conditions in survivors of DLBCL compared with other cancer survivors, including significantly and consistently elevated IRRs for viral and fungal pneumonias (up to 10.8-fold), meningitis (up to 5.3-fold), as well as humoral deficiency (up to 17.6-fold) and autoimmune cytopenias (up to 12-fold). IRRs for most conditions remained high even in the late survivorship period (5-10 years after cancer diagnosis). The elevated risks could not be explained by exposure to chemotherapy, stem-cell transplantation, or rituximab, except for IRRs for humoral deficiency, which were consistently higher after the incorporation of rituximab into DLBCL treatments. CONCLUSION To our knowledge, this is the largest cohort study with extended follow-up to demonstrate impaired immune health in survivors of DLBCL. The observed persistent, elevated risks for autoimmune diseases, immune deficiencies, and infectious conditions may reflect persistent immune dysregulation caused by lymphoma or treatment and may lead to excess morbidity and mortality during survivorship. Improved understanding of these risks could meaningfully improve long-term care of patients with DLBCL.
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Affiliation(s)
- Tanaya Shree
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Qian Li
- Center for Oncology Hematology Outcomes Research and Training (COHORT) and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA
| | | | - Ann Brunson
- Center for Oncology Hematology Outcomes Research and Training (COHORT) and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA
| | - Holden T. Maecker
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA
| | - Robert W. Haile
- Center for Translational Population Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ronald Levy
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Theresa H. M. Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT) and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA
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Bastos-Oreiro M, Muntañola A, Panizo C, Gonzalez-Barca E, de Villambrosia SG, Córdoba R, López JLB, González-Sierra P, Terol MJ, Gutierrez A, Grande C, Ramirez MJ, Iserte L, Perez E, Navarro B, Gomez P, Salar A, Luzardo H, López A, Del Campo R, García-Belmonte D, Vida MJ, Infante M, Queizan-Hernandez JA, Novelli S, Moreno M, Penarrubia M, Gómez J, Domingo A, Donato E, Viguria MC, López F, Rodriguez MJ, Pardal E, Noriega V, Andreu R, Peñalver J, Martín A, Caballero D, López-Guillermo A. RELINF: prospective epidemiological registry of lymphoid neoplasms in Spain. A project from the GELTAMO group. Ann Hematol 2020; 99:799-808. [PMID: 32076827 DOI: 10.1007/s00277-020-03918-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 01/13/2020] [Indexed: 12/17/2022]
Abstract
Lymphomas are a large, heterogeneous group of neoplasms with well-defined characteristics, and this heterogeneity highlights the importance of epidemiological data. Knowledge of local epidemiology is essential to optimise resources, design clinical trials, and identify minority entities. Given there are few published epidemiological data on lymphoma in Spain, the Spanish Lymphoma and Autologous Bone Marrow Transplant Group created the RELINF project. The aim of this project is to determine the frequencies and distribution of lymphoid neoplasms in Spain and to analyse survival. We developed an online platform for the prospective collection of data on newly diagnosed cases of lymphoma in Spain between January 2014 and July 2018; 11,400 patients were registered. Diffuse large B cell lymphoma (DLBCL) and follicular lymphoma (FL) were the most frequent lymphomas in our series. Marginal B cell lymphoma frequency was higher than that reported in other studies, representing more than 11% of mature B cell lymphomas. Peripheral T cell lymphoma not otherwise specified (PTCL-NOS) was the most common subtype of T cell lymphoma, and NK/T cell lymphomas were more frequent than expected (5.4% of total). Hodgkin's lymphoma accounted for 12% of lymphoproliferative syndromes. Overall survival was greater than 90% at 2 years for indolent B cell lymphomas, and approximately 60% for DLBCL, somewhat lower than that previously reported. Survival was poor for PTCL-NOS and angioimmunoblastic T cell lymphoma, as expected; however, it was somewhat better than that in other studies for anaplastic large cell anaplastic lymphoma kinase lymphomas. This is the first prospective registry to report the frequencies, distribution, and survival of lymphomas in Spain. The frequencies and survival data we report here are globally consistent with that reported in other Western countries. These updated frequencies and survival statistics are necessary for developing appropriate management strategies for neoplasias in the Spanish population.
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Affiliation(s)
- Mariana Bastos-Oreiro
- Haematology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain. .,Health Research Institute, Gregorio Marañon, Madrid, Spain.
| | - Ana Muntañola
- Haematology Department, Hospital Universitario Mutua Tarrasa, Tarrasa, Cataluña, Spain
| | - Carlos Panizo
- Haematology Department, Clínica Universitaria de Navarra, Navarra, Spain
| | - Eva Gonzalez-Barca
- Haematology Department, ICO Duran y Reinalds, Bellvitlle, Cataluña, Spain
| | | | - Raúl Córdoba
- Haematology Department, Fundación Jimenez Díaz, Madrid, Madrid, Spain
| | - Jose Luís Bello López
- Haematology Department, University of Santiago Hospital Clinic, Santiago de Compostela, Galicia, Spain
| | | | - María José Terol
- Haematology Department, Valencia Hospital Clinic, Valencia, Spain
| | - Antonio Gutierrez
- Haematology Department, Hospital Son Espases, Palma de Mallorca, Spain
| | - Carlos Grande
- Haematology Department, Hospital 12 de Octubre, Madrid, Spain
| | | | - Laura Iserte
- Haematology Department, Hospital Arnau de Vilanova, Lleida, Cataluña, Spain
| | - Elena Perez
- Haematology department, Hospital Morales Meseguer, Murcia, Murcia, Spain
| | - Belén Navarro
- Haematology Department, University Hospital Puerta de Hierro, Mahadahonda, Madrid, Spain
| | - Pilar Gomez
- Haematology Department, La Paz University Hospital, Madrid, Spain
| | - Antonio Salar
- Haematology Department, Hospital del Mar, Barcelona, Cataluña, Spain
| | - Hugo Luzardo
- Hospital Negrin, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - Andrés López
- Haematology Department, Hospital Vall d' Hebron, Barcelona, Cataluña, Spain
| | - Raquel Del Campo
- Haematology Department, Hospital Son Llátzer, Palma de Mallorca, Spain
| | | | - María Jesús Vida
- Haematology Department, Hospital of León, León, Castilla y León, Spain
| | - María Infante
- Haematology Department, Hospital Infanta Leonor, Madrid, Spain
| | | | - Silvana Novelli
- Haematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Cataluña, Spain
| | - Miriam Moreno
- Haematology Department, Hospital Germans Trials y Pujol, Badalona, Cataluña, Spain
| | - Miriam Penarrubia
- Haematology Department, Hospital Clinic of Valladolid, Castilla y León, Spain
| | - Joaquín Gómez
- Haematology Department, Hospital Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Abel Domingo
- Haematology Department, Hospital de Granollers, Barcelona, Cataluña, Spain
| | - Eva Donato
- Haematology Department, Hospital Dr. Peset, Valencia, Spain
| | | | | | - María José Rodriguez
- Haematology Department, Hospital Universitario de Canarias SCT, Tenerife, Canary Islands, Spain
| | - Emilia Pardal
- Haematology Department, Hospital Virgen del Puerto, Cáceres, Extremadura, Spain
| | - Victor Noriega
- Haematology Department, University Hospital A Coruña, A Coruña, Galicia, Spain
| | - Rafael Andreu
- Haematology Department, Hospital La Fe, Valencia, Spain
| | - Javier Peñalver
- Haematology Department, Hospital of Alcorcón, Alcorcón, Madrid, Spain
| | - Alejandro Martín
- Haematology Department, Hospital Clinic of Salamanca, Salamanca, Castilla y León, Spain
| | - Dolores Caballero
- Haematology Department, Hospital Clinic of Salamanca, Salamanca, Castilla y León, Spain
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Quality Initiative in Clinical Practice: A Single-Institution Appraisal of Quality Metrics in the Management of Newly Diagnosed Diffuse Large B-Cell Lymphoma. Mayo Clin Proc Innov Qual Outcomes 2020; 3:485-494. [PMID: 31993568 PMCID: PMC6978588 DOI: 10.1016/j.mayocpiqo.2019.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/30/2019] [Accepted: 08/23/2019] [Indexed: 11/22/2022] Open
Abstract
Objective To assess our adherence to treatment guidelines for diffuse large B-cell lymphoma (DLBCL) established by the American Society of Hematology in 2014 through implementation of a quality improvement initiative (QII) at our institution in 2015. Patients and Methods Patients with newly diagnosed DLBCL treated from January 1, 2006, through December 31, 2017, were identified. Electronic medical records were reviewed for documentation of American Society of Hematology Practice Improvement Module quality measures (eg, key pathologic features of DLBCL, lymphoma staging, and screening for hepatitis B virus [HBV] infection in patients receiving rituximab-based chemotherapy). We also reviewed assessment of prognosis by revised International Prognostic Index score, testing for hepatitis C virus, HBV, and HIV, chemotherapy education, and the addition of rituximab in the treatment regimen of CD20+ DLBCL. Results Following QII implementation, we saw improvements in most metrics, including reporting of key molecular features (fluorescence in situ hybridization for c-MYC, BCL2, and BCL6, from 45.5% [75 of 165 patients] before QII to 91.7% [22 of 24 patients] after QII; P<.001), screening for HBV (41.8% [69 of 165 patients] to 91.7% [22 of 24 patients]; P<.001) and HIV infections (33.9% [56 of 165 patients] to 87.5% [21 of 24 patients]; P<.0001), providing chemotherapy education (92.7% [153 of 165 patients] to 100%), and use of rituximab for CD20+ DLBCL (83.6% [138 of 165 patients] to 100%; P=.05). All patients had positron emission tomography–computed tomography for DLBCL staging, and there was significantly lower use of bone marrow biopsy (P=.011). Conclusion Implementating a QII and employing standardized metrics can aid in improving quality of care for patients with newly diagnosed DLBCL and allow opportunities to build and ensure better adherence to evolving patient care guidelines.
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Key Words
- ASH-PIM, American Society of Hematology Practice Improvement Module
- BMB, bone marrow biopsy
- CT, computed tomography
- DLBCL, diffuse large B-cell lymphoma
- EMR, electronic medical record
- G-CSF, granulocyte colony-stimulating factor
- HAART, highly active antiretroviral therapy
- HBV, hepatitis B virus
- HCV, hepatitis C virus
- NHL, non-Hodgkin lymphoma
- PET, positron emission tomography
- QII, quality improvement initiative
- R-CHOP, rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone
- VMMC, Virginia Mason Medical Center
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Guadamuz JS, Ozenberger K, Qato DM, Ko NY, Saffore CD, Adimadhyam S, Cha AS, Moran KM, Sweiss K, Patel PR, Chiu BCH, Calip GS. Mediation analyses of socioeconomic factors determining racial differences in the treatment of diffuse large B-cell lymphoma in a cohort of older adults. Medicine (Baltimore) 2019; 98:e17960. [PMID: 31725657 PMCID: PMC6867777 DOI: 10.1097/md.0000000000017960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Despite near universal health coverage under Medicare, racial disparities persist in the treatment of diffuse large B-cell lymphoma (DLBCL) among older patients in the United States. Studies evaluating DLBCL outcomes often treat socioeconomic status (SES) measures as confounders, potentially introducing biases when SES factors are mediators of disparities in cancer treatment.To examine differences in DLBCL treatment, we performed causal mediation analyses of SES measures, including: metropolitan statistical area (MSA) of residence; census-tract poverty level; and private Medicare supplementation using the Surveillance, Epidemiology and End Results-Medicare linked database between 2001 and 2011. In this retrospective cohort study of DLBCL patients ages 66+ years, we conducted a series of multivariable logistic regression analyses estimating odds ratios (OR) and 95% confidence intervals (CI) relating chemo- and/or immuno-therapy treatment and each SES measure, comparing non-Hispanic (NH)-black, Hispanic/Latino, and Asian/Pacific Islander (API) to NH-white patients.Compared to NH-white patients, racial/ethnic minority patients had lower odds of receiving chemo- and/or immuno-therapy treatment (NH-black: OR 0.84, 95% CI 0.65, 1.08; API: OR 0.80, 95% CI 0.64, 1.01; Hispanic/Latino: OR 0.78, 95% CI 0.64, 0.96) and higher odds of lacking private Medicare supplementation and residence within an urban MSA and poor census tracts. Adjustment for SES measures as confounders nullified observed racial differences. In causal mediation analyses, between 31% and 38% of race/ethnicity differences were mediated by having private Medicare supplementation.Providing equitable access to Medicare supplementation may reduce disparities in receipt of chemo- and/or immuno-therapy treatment in older DLBCL patients.
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Affiliation(s)
- Jenny S. Guadamuz
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
- Institute of Minority of Health Research, University of Illinois at Chicago
| | - Katharine Ozenberger
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
| | - Dima M. Qato
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
- Division of Biostatistics and Epidemiology, University of Illinois at Chicago, Chicago, IL
| | - Naomi Y. Ko
- Section of Hematology Oncology, Boston University School of Medicine, Boston, MA
| | | | - Sruthi Adimadhyam
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
| | - Ashley S. Cha
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
| | - Kellyn M. Moran
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
| | - Karen Sweiss
- Department of Pharmacy Practice, University of Illinois at Chicago
| | - Pritesh R. Patel
- Division of Hematology Oncology, University of Illinois at Chicago
| | - Brian C.-H. Chiu
- Department of Public Health Sciences, The University of Chicago, Chicago, IL
| | - Gregory S. Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
- Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
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Harkins RA, Chang A, Patel SP, Lee MJ, Goldstein JS, Merdan S, Flowers CR, Koff JL. Remaining challenges in predicting patient outcomes for diffuse large B-cell lymphoma. Expert Rev Hematol 2019; 12:959-973. [PMID: 31513757 PMCID: PMC6821591 DOI: 10.1080/17474086.2019.1660159] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/22/2019] [Indexed: 12/28/2022]
Abstract
Introduction: Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin lymphoma and is an aggressive malignancy with heterogeneous outcomes. Diverse methods for DLBCL outcomes assessment ranging from clinical to genomic have been developed with variable predictive and prognostic success.Areas covered: The authors provide an overview of the various methods currently used to estimate prognosis in DLBCL patients. Models incorporating cell of origin, genomic features, sociodemographic factors, treatment effectiveness measures, and machine learning are described.Expert opinion: The clinical and genetic heterogeneity of DLBCL presents distinct challenges in predicting response to therapy and overall prognosis. Successful integration of predictive and prognostic tools in clinical trials and in a standard clinical workflow for DLBCL will likely require a combination of methods incorporating clinical, sociodemographic, and molecular factors with the aid of machine learning and high-dimensional data analysis.
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Affiliation(s)
- R. Andrew Harkins
- Emory University School of Medicine, Atlanta, Georgia 30322-1007, USA
| | - Andres Chang
- Winship Cancer Institute of Emory University, Atlanta, Georgia 30322-1007, USA
| | | | - Michelle J. Lee
- Emory University School of Medicine, Atlanta, Georgia 30322-1007, USA
| | | | - Selin Merdan
- Winship Cancer Institute of Emory University, Atlanta, Georgia 30322-1007, USA
- Georgia Institute of Technology, Atlanta, Georgia 30332-0002, USA
| | | | - Jean L. Koff
- Winship Cancer Institute of Emory University, Atlanta, Georgia 30322-1007, USA
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Le M, Ghazawi FM, Alakel A, Netchiporouk E, Rahme E, Zubarev A, Powell M, Moreau L, Roshdy O, Glassman SJ, Sasseville D, Popradi G, Litvinov IV. Incidence and mortality trends and geographic patterns of follicular lymphoma in Canada. ACTA ACUST UNITED AC 2019; 26:e473-e481. [PMID: 31548815 DOI: 10.3747/co.26.4625] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Follicular lymphoma (fl) is the most common indolent lymphoma and the 2nd most common non-Hodgkin lymphoma, accounting for 10%-20% of all lymphomas in the Western world. Epidemiologic and geographic trends of fl in Canada have not been investigated. Our study's objective was to analyze incidence and mortality rates and the geographic distribution of fl patients in Canada for 1992-2010. Methods Demographic and geographic patient data for fl cases were obtained using the Canadian Cancer Registry, the Registre québécois du cancer, and the Canadian Vital Statistics database. Incidence and mortality rates and 95% confidence intervals were calculated per year and per geographic area. Rates were plotted using linear regression models to assess trends over time. Overall data were mapped using Microsoft Excel mapping software (Redmond, WA, U.S.A.) to identify case clusters across Canada. Results Approximately 22,625 patients were diagnosed with fl during 1992-2010. The age-standardized incidence rate of this malignancy in Canada was 38.3 cases per million individuals per year. Geographic analysis demonstrated that a number of Maritime provinces and Manitoba had the highest incidence rates, and that the provinces of Nova Scotia and Quebec had the highest mortality rates in the nation. Regional data demonstrated clustering of fl within cities or regions with high herbicide use, primary mining, and a strong manufacturing presence. Conclusions Our study provides a comprehensive overview of the fl burden and its geographic distribution in Canada. Regional clustering of this disease in concentrated industrial zones strongly suggests that multiple environmental factors might play a crucial role in the development of this lymphoma.
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Affiliation(s)
- M Le
- Division of Dermatology, McGill University, Montreal, QC
| | - F M Ghazawi
- Division of Dermatology, University of Ottawa, Ottawa, ON
| | - A Alakel
- The Ottawa Hospital Research Institute, Ottawa, ON
| | - E Netchiporouk
- Division of Dermatology, McGill University, Montreal, QC
| | - E Rahme
- Division of Clinical Epidemiology, McGill University, Montreal, QC
| | - A Zubarev
- Division of Dermatology, McGill University, Montreal, QC
| | - M Powell
- Division of Dermatology, McGill University, Montreal, QC
| | - L Moreau
- Division of Dermatology, McGill University, Montreal, QC
| | - O Roshdy
- Division of Dermatology, McGill University, Montreal, QC
| | - S J Glassman
- Division of Dermatology, University of Ottawa, Ottawa, ON
| | - D Sasseville
- Division of Dermatology, McGill University, Montreal, QC
| | - G Popradi
- Division of Hematology, McGill University, Montreal, QC
| | - I V Litvinov
- Division of Dermatology, McGill University, Montreal, QC.,Division of Dermatology, University of Ottawa, Ottawa, ON
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Ritter AJ, Goldstein JS, Ayers AA, Flowers CR. Rural and urban patients with diffuse large B-cell and follicular lymphoma experience reduced overall survival: a National Cancer DataBase study. Leuk Lymphoma 2019; 60:1656-1667. [PMID: 30632824 PMCID: PMC6594869 DOI: 10.1080/10428194.2018.1546855] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 10/31/2018] [Indexed: 12/27/2022]
Abstract
We examined 83,108 patients with diffuse large B-cell lymphoma (DLBCL) and 43,393 patients with follicular lymphoma (FL) to investigate disparities related to geographic population density, stratified as rural, urban, or metropolitan. We found that urban and rural patients less commonly had private insurance and high socioeconomic status. Urban and rural DLBCL patients were more likely to receive treatment within 14 days of diagnosis (OR 0.93, 95% confidence interval [CI] 0.89-0.98; and OR 0.81, 95% CI 0.72-0.91) while urban FL patients were more likely to have treatment >14 days after diagnosis (OR 1.08, 95% CI 1.01-1.16). Multivariable analyses demonstrated that rural and urban patients had worse overall survival with DLBCL (hazard ratio [HR] 1.09; 95% CI 1-1.19 and HR 1.08; 95% CI 1.04-1.11) and FL (HR 1.11; 95% CI 1.04-1.18 and HR 1.2; 95% CI 1.02-1.41), respectively, suggesting needs for focused study and interventions for these populations.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Cities
- Databases, Factual
- Female
- Follow-Up Studies
- Georgia/epidemiology
- Humans
- Lymphoma, Follicular/epidemiology
- Lymphoma, Follicular/mortality
- Lymphoma, Follicular/pathology
- Lymphoma, Large B-Cell, Diffuse/epidemiology
- Lymphoma, Large B-Cell, Diffuse/mortality
- Lymphoma, Large B-Cell, Diffuse/pathology
- Male
- Middle Aged
- Prognosis
- Retrospective Studies
- Rural Population/statistics & numerical data
- Social Class
- Survival Rate
- Urban Population/statistics & numerical data
- Young Adult
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Affiliation(s)
| | | | - Amy A Ayers
- b Winship Cancer Institute , Atlanta , GA , USA
| | - Christopher R Flowers
- b Winship Cancer Institute , Atlanta , GA , USA
- c Department of Hematology and Medical Oncology , Emory University School of Medicine , Atlanta , GA , USA
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Characterizing Lymphoma Incidence and Disparities for a Cancer Center Catchment Region. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:699-708.e5. [PMID: 31494062 DOI: 10.1016/j.clml.2019.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/07/2019] [Accepted: 06/17/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Racial disparities in non-Hodgkin lymphoma (NHL) are not well-elucidated for specific catchment areas, which can influence outcomes. Leveraging regional data from a population-based cancer registry may provide unique opportunities to quantify NHL disparities. MATERIALS AND METHODS Using Surveillance, Epidemiology, and End Results (SEER) data for NHL cases diagnosed in Georgia from 2001 to 2015, we examined NHL incidence rates by lymphoma subtype and racial differences in baseline characteristics and outcomes for diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL). Cox regression models identified predictors of overall survival (OS). RESULTS SEER documented 38,504 NHL cases in Georgia from 2001 to 2015. The age-adjusted incidence rate for NHL in Georgia increased 1.03% per year, and the annual percentage change was 1.72 in blacks compared with 0.84 in whites. Compared with whites, blacks with DLBCL and FL were more likely to be diagnosed at a younger age (DLBCL, 54.1 vs. 65.5 years; P < .0001; FL, 58.4 vs. 64.0 years; P < .0001) and with B symptoms (DLBCL, 44.4% vs. 33.4%; P < .0001; FL, 28.5% vs. 21.4%; P = .004). Across racial categories, age at diagnosis > 60 years, advanced stage, and B symptoms predicted worse OS in DLBCL and FL. Blacks with DLBCL more commonly were diagnosed with stage III/IV disease (55.5% vs. 48.1%; P < .0001) and had worse 5-year relative survival (58.8% vs. 62.3%; P = .01). CONCLUSIONS Regional cancer registry data can be used to define incidence patterns and disparities in outcomes across NHL subtypes to help define key targets for interventions in a catchment area.
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Çağlayan Ç, Goldstein JS, Ayer T, Rai A, Flowers CR. A population-based multistate model for diffuse large B-cell lymphoma-specific mortality in older patients. Cancer 2019; 125:1837-1847. [PMID: 30707765 PMCID: PMC6509004 DOI: 10.1002/cncr.31981] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/17/2018] [Accepted: 12/07/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite effective therapies, outcomes for diffuse large B-cell lymphoma (DLCBL) remain heterogeneous in older individuals due to comorbid diseases and variations in disease biology. METHODS Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, the authors conducted a multistate survival analysis of 11,780 patients with DLBCL who were aged ≥65 years at the time of diagnosis (2002-2009). Cox proportional hazards models were used to specify the impact of prognostic factors on overall survival and cause-specific deaths, and the Aalen-Johansen estimator was used to project the course of DLBCL over time with or without standard therapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). RESULTS Advanced age (hazard ratio [HR] for ages 71-75 years: 1.25; HR for ages 76-80 years: 1.46; HR for ages 81-85 years: 1.88; and HR for age ≥86 years: 2.26), DLBCL stage (HR for Ann Arbor stage II: 1.28; HR for stage III: 1.54; and HR for stage IV: 1.95), Charlson Comorbidity Index (CCI) ≥1 (HR for CCI of 1, 1.15; and HR for CCI >1, 1.37), and not being married (HR, 1.12) were associated with an increased risk of DLBCL-specific death. Being female (HR, 0.91) and of higher socioeconomic status (HR, 0.91) were associated with a lower risk of DLBCL-related mortality after therapy. For patients treated with R-CHOP (3610 patients), the risk of death due to DLBCL was 14.0% and 18.6%, respectively, at 2 and 5 years of treatment and plateaued afterward, confirming a 5-year "cure" point while receiving R-CHOP among older patients. CONCLUSIONS Conducting a survival analysis over a large data set, the current study evaluated competing risks for death within a multistate modeling framework, and identified age, sex, and CCI as risk factors for DLBCL-specific and other causes of death.
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Affiliation(s)
- Çağlar Çağlayan
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | | | - Turgay Ayer
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Ashish Rai
- Outcomes Research, Surveillance and Health Services Research Program, American Cancer Society Inc, Atlanta, Georgia
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