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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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2
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Charlot M, Corbie G. Delivery of Novel Therapies without Ensuring Equitable Access - Are Cancer Centers Putting the CART19 before the Horse? NEJM EVIDENCE 2024; 3:EVIDe2400030. [PMID: 38805626 DOI: 10.1056/evide2400030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Affiliation(s)
- Marjory Charlot
- Division of Oncology, University of North Carolia at Chapel Hill, Chapel Hill
| | - Giselle Corbie
- Departments of Social Medicine and Medicine, University of North Carolia at Chapel Hill, Chapel Hill
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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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Aleynick M, Svensson-Arvelund J, Pantsulaia G, Kim K, Rose SA, Upadhyay R, Yellin M, Marsh H, Oreper D, Jhunjhunwala S, Moussion CC, Merad M, Brown BD, Brody JD. Pattern recognition receptor agonists in pathogen vaccines mediate antitumor T-cell cross-priming. J Immunother Cancer 2023; 11:e007198. [PMID: 37487664 PMCID: PMC10373699 DOI: 10.1136/jitc-2023-007198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Cancer immunotherapies are generally effective in patients whose tumors contain a priori primed T-cells reactive to tumor antigens (TA). One approach to prime TA-reactive T-cells is to administer immunostimulatory molecules, cells, or pathogens directly to the tumor site, that is, in situ vaccination (ISV). We recently described an ISV using Flt3L to expand and recruit dendritic cells (DC), radiotherapy to load DC with TA, and pattern recognition receptor agonists (PRRa) to activate TA-loaded DC. While ISV trials using synthetic PRRa have yielded systemic tumor regressions, the optimal method to activate DCs is unknown. METHODS To discover optimal DC activators and increase access to clinical grade reagents, we assessed whether viral or bacterial components found in common pathogen vaccines are an effective source of natural PRRa (naPRRa). Using deep profiling (155-metric) of naPRRa immunomodulatory effects and gene editing of specific PRR, we defined specific signatures and molecular mechanisms by which naPRRa potentiate T-cell priming. RESULTS We observed that vaccine naPRRa can be even more potent in activating Flt3L-expanded murine and human DCs than synthetic PRRa, promoting cross-priming of TA-reactive T-cells. We developed a mechanistically diverse naPRRa combination (BCG, PedvaxHIB, Rabies) and noted more potent T-cell cross-priming than with any single naPRRa. The naPRRa triplet-as part of Flt3L-primed ISV-induced greater intratumoral CD8 T-cell infiltration, T-cells reactive to a newly defined tumorous neoantigen, durable tumor regressions. CONCLUSIONS This work provides rationale for the translation of pathogen vaccines as FDA-approved clinical-grade DC activators which could be exploited as immune-stimulants for early phase trials.
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Affiliation(s)
- Mark Aleynick
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Marc and Jennifer Lipschultz Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Judit Svensson-Arvelund
- Marc and Jennifer Lipschultz Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gvantsa Pantsulaia
- Marc and Jennifer Lipschultz Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kristy Kim
- Marc and Jennifer Lipschultz Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel A Rose
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Marc and Jennifer Lipschultz Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ranjan Upadhyay
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Marc and Jennifer Lipschultz Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Henry Marsh
- Celldex Therapeutics Inc, Hampton, New Jersey, USA
| | | | | | | | - Miriam Merad
- Marc and Jennifer Lipschultz Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian D Brown
- Marc and Jennifer Lipschultz Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua D Brody
- Marc and Jennifer Lipschultz Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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5
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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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Lucero KT, Obodozie-Ofoegbu OO, Nooruddin Z, Ryan K, Castillo A, Moore AM, Jones X, Frei CR. Health disparity in use of novel agents for first-line therapy in Black and White patients with chronic lymphocytic leukemia in the Department of Veterans Affairs. J Manag Care Spec Pharm 2023; 29:420-430. [PMID: 36989449 PMCID: PMC10387978 DOI: 10.18553/jmcp.2023.29.4.420] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
BACKGROUND: Novel agents (NAs) (ibrutinib, idelalisib, and venetoclax) were first introduced in 2013 as therapeutic options to treat chronic lymphocytic leukemia (CLL). OBJECTIVES: To determine if the uptake of NAs for first-line treatment was similar in Black and White patients with CLL treated in the Department of Veterans Affairs (VA). METHODS: We conducted a retrospective cohort study including adults with CLL managed in the VA from October 1, 2013, to September 30, 2017. Descriptive statistics were used to summarize demographic data, and appropriate bivariable statistical tests were used to compare NA use, baseline characteristics, health outcomes, and complications. A multivariable logistic regression model was used to identify factors associated with uptake of NAs. The study included 565 patients; 86% were White and 14% were Black. Black patients were younger than White patients (median age [66 vs 69 years; P < 0.01]) but had similar median baseline Charlson comorbidity scores (4 vs 5). RESULTS: Overall, Black patients were less likely to receive NAs than White patients (14% vs 26%; P = 0.02). The gap narrowed over the study period: 4% vs 17% (2014), 13% vs 25% (2015), 17% vs 33% (2016), and 31% vs 33% (2017). Black race (P = 0.02) and fiscal year (P < 0.01) were the only variables significantly associated with NA use in the multivariable model. Health outcomes and most complications were similar for Black and White patients despite the difference in prescribing patterns. CONCLUSIONS: This is the first study to identify a potential health disparity with respect to use of NAs among Black and White patients with CLL treated in the VA. Fortunately, health outcomes and most complications were similar for Black and White patients despite the difference in prescribing patterns. DISCLOSURES: Funding for the study was provided by AstraZeneca as a research grant to the Foundation for Advancing Veterans' Health Research (FAVHR), a non-profit entity within the Audie L. Murphy Veterans Hospital, San Antonio, TX. Drs Nooruddin and Frei have received research grants (paid to FAVHR) from AstraZeneca in the last 3 years. Ms Ryan is an employee of AstraZeneca. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the National Institutes of Health, or the authors' affiliated institutions.
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Affiliation(s)
- Kana Tai Lucero
- Long School of Medicine, University of Texas Health San Antonio
- South Texas Veterans Health Care System, San Antonio
| | - Obiageri O Obodozie-Ofoegbu
- Long School of Medicine, University of Texas Health San Antonio
- College of Pharmacy, The University of Texas at Austin, San Antonio
| | - Zohra Nooruddin
- Long School of Medicine, University of Texas Health San Antonio
- South Texas Veterans Health Care System, San Antonio
| | - Kellie Ryan
- AstraZeneca US Medical Affairs, Gaithersburg, MD
| | - Alyssa Castillo
- Long School of Medicine, University of Texas Health San Antonio
- College of Pharmacy, The University of Texas at Austin, San Antonio
| | - Amanda M Moore
- College of Pharmacy, The University of Texas at Austin, San Antonio
| | - Xavier Jones
- Long School of Medicine, University of Texas Health San Antonio
- South Texas Veterans Health Care System, San Antonio
- College of Pharmacy, The University of Texas at Austin, San Antonio
| | - Christopher R Frei
- Long School of Medicine, University of Texas Health San Antonio
- South Texas Veterans Health Care System, San Antonio
- College of Pharmacy, The University of Texas at Austin, San Antonio
- University Health System, San Antonio, TX
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7
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Dhar L, Singh S, Jain S, Vindal A, Sinha P, Gautam R. Cell of origin classification of diffuse large B-Cell lymphoma. J Microsc Ultrastruct 2023. [DOI: 10.4103/jmau.jmau_66_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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8
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Svensson-Arvelund J, Cuadrado-Castano S, Pantsulaia G, Kim K, Aleynick M, Hammerich L, Upadhyay R, Yellin M, Marsh H, Oreper D, Jhunjhunwala S, Moussion C, Merad M, Brown BD, García-Sastre A, Brody JD. Expanding cross-presenting dendritic cells enhances oncolytic virotherapy and is critical for long-term anti-tumor immunity. Nat Commun 2022; 13:7149. [PMID: 36418317 PMCID: PMC9684150 DOI: 10.1038/s41467-022-34791-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
Immunotherapies directly enhancing anti-tumor CD8+ T cell responses have yielded measurable but limited success, highlighting the need for alternatives. Anti-tumor T cell responses critically depend on antigen presenting dendritic cells (DC), and enhancing mobilization, antigen loading and activation of these cells represent an attractive possibility to potentiate T cell based therapies. Here we show that expansion of DCs by Flt3L administration impacts in situ vaccination with oncolytic Newcastle Disease Virus (NDV). Mechanistically, NDV activates DCs and sensitizes them to dying tumor cells through upregulation of dead-cell receptors and synergizes with Flt3L to promote anti-tumor CD8+ T cell cross-priming. In vivo, Flt3L-NDV in situ vaccination induces parallel amplification of virus- and tumor-specific T cells, including CD8+ T cells reactive to newly-described neoepitopes, promoting long-term tumor control. Cross-presenting conventional Type 1 DCs are indispensable for the anti-tumor, but not anti-viral, T cell response, and type I IFN-dependent CD4+ Th1 effector cells contribute to optimal anti-tumor immunity. These data demonstrate that mobilizing DCs to increase tumor antigen cross-presentation improves oncolytic virotherapy and that neoepitope-specific T cells can be induced without individualized, ex vivo manufactured vaccines.
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Affiliation(s)
- Judit Svensson-Arvelund
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
- Division of Molecular Medicine and Virology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, 582 25, Sweden.
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
| | - Sara Cuadrado-Castano
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Gvantsa Pantsulaia
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Kristy Kim
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Mark Aleynick
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Linda Hammerich
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Hepatology and Gastroenterology, Campus Virchow- Klinikum, Charité Universitätsmedizin Berlin, Berlin, 13353, Germany
| | - Ranjan Upadhyay
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | | | - Henry Marsh
- Celldex Therapeutics, Inc, Needham, MA, 02494, USA
| | | | | | | | - Miriam Merad
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- The Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Brian D Brown
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- The Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Adolfo García-Sastre
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Global Health Emerging Pathogens Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Joshua D Brody
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
- The Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
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9
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Manz CR, Tramontano AC, Uno H, Parikh RB, Bekelman JE, Schrag D. Association of Oncologist Participation in Medicare's Oncology Care Model With Patient Receipt of Novel Cancer Therapies. JAMA Netw Open 2022; 5:e2234161. [PMID: 36173630 PMCID: PMC9523492 DOI: 10.1001/jamanetworkopen.2022.34161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Medicare's Oncology Care Model (OCM) was an alternative payment model that tied performance-based payments to cost and quality goals for participating oncology practices. A major concern about the OCM regarded inclusion of high-cost cancer therapies, which could potentially disincentivize oncologists from prescribing novel therapies. OBJECTIVE To examine whether oncologist participation in the OCM changed the likelihood that patients received novel therapies vs alternative treatments. DESIGN, SETTING, AND PARTICIPANTS This cohort study of Surveillance, Epidemiology, and End Results (SEER) Program data and Medicare claims compared patient receipt of novel therapies for patients treated by oncologists participating vs not participating in the OCM in the period before (January 2015-June 2016) and after (July 2016-December 2018) OCM initiation. Participants included Medicare fee-for-service beneficiaries in SEER registries who were eligible to receive 1 of 10 novel cancer therapies that received US Food and Drug Administration approval in the 18 months before implementation of the OCM. The study excluded the Hawaii registry because complete data were not available at the time of the data request. Patients in the OCM vs non-OCM groups were matched on novel therapy cohort, outcome time period, and oncologist specialist status. Analysis was conducted between July 2021 and April 2022. EXPOSURES Oncologist participation in the OCM. MAIN OUTCOMES AND MEASURES Preplanned analyses evaluated patient receipt of 1 of 10 novel therapies vs alternative therapies specific to the patient's cancer for the overall study sample and for racial subgroups. RESULTS The study included 2839 matched patients (760 in the OCM group and 2079 in the non-OCM group; median [IQR] age, 72.7 [68.3-77.6] years; 1591 women [56.0%]). Among patients in the non-OCM group, 33.2% received novel therapies before and 40.1% received novel therapies after the start of the OCM vs 39.9% and 50.3% of patients in the OCM group (adjusted difference-in-differences, 3.5 percentage points; 95% CI, -3.7 to 10.7 percentage points; P = .34). In subgroup analyses, second-line immunotherapy use in lung cancer was greater among patients in the OCM group vs non-OCM group (adjusted difference-in-differences, 17.4 percentage points; 95% CI, 4.8-30.0 percentage points; P = .007), but no differences were seen in other subgroups. Over the entire study period, patients with oncologists participating in the OCM were more likely to receive novel therapies than those with oncologists who were not participating (odds ratio, 1.47; 95% CI, 1.09-1.97; P = .01). CONCLUSIONS AND RELEVANCE This study found that participation in the OCM was not associated with oncologists' prescribing novel therapies to Medicare beneficiaries with cancer. These findings suggest that OCM financial incentives did not decrease patient access to novel therapies.
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Affiliation(s)
- Christopher R. Manz
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medical Oncology, Harvard Medical School, Boston, Massachusetts
| | - Angela C. Tramontano
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ravi B. Parikh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Justin E. Bekelman
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Deborah Schrag
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Sariahmed K, Kurian J, Singh AK, Leyton C, Minuti A, Jerschow E, Arora S, Jariwala SP. Social, political, and economic determinants of access to biologics: A scoping review of structural determinants in the clinical disparities literature. Res Social Adm Pharm 2022; 18:4038-4047. [DOI: 10.1016/j.sapharm.2022.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 05/05/2022] [Accepted: 07/28/2022] [Indexed: 02/07/2023]
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11
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Ahmed N, Shahzad M, Shippey E, Bansal R, Mushtaq MU, Mahmoudjafari Z, Faisal MS, Hoffmann M, Abdallah AO, Divine C, Hamadani M, McGuirk J, Shune L. Socioeconomic and Racial Disparity in Chimeric antigen receptor T cell (CAR T) Therapy Access. Transplant Cell Ther 2022; 28:358-364. [DOI: 10.1016/j.jtct.2022.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/22/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022]
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12
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Gupta A, Zhang D, Braithwaite D, Karanth SD, Tailor TD, Clarke JM, Akinyemiju T. Racial Differences in Survival Among Advanced-stage Non-small-Cell Lung Cancer Patients Who Received Immunotherapy: An Analysis of the US National Cancer Database (NCDB). J Immunother 2022; 45:132-137. [PMID: 34747372 DOI: 10.1097/cji.0000000000000400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022]
Abstract
Lung cancer is the most common cause of cancer death among men and women in the United States, with significant racial disparities in survival. It is unclear whether these disparities persist upon equal utilization of immunotherapy. The purpose of this study was to evaluate the association between race and all-cause mortality among non-small-cell lung cancer (NSCLC) patients who received immunotherapy. We obtained data from the 2016 National Cancer Database on patients diagnosed with advanced-stage (III-IV) NSCLC from 2015 to 2016. Multivariable Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (95% CI) by race/ethnicity. A total of 2940 patients were included. Non-Hispanic (NH)-Black patients had a lower risk of death relative to NH-White patients (HR: 0.85; 95% CI: 0.73, 0.98) after adjusting for sociodemographic, clinical, and treatment factors. Formal tests of interaction evaluating race with Charlson-Deyo comorbidity score and race with area-level median income were nonsignificant. However, in stratified analyses, NH-Black versus NH-White patients had a lower risk of death in models adjusted for sociodemographic factors among those with at least 1 comorbidity (HR: 0.75; 95% CI: 0.57, 0.97), and those living in regions within the 2 lowest quartiles of median income (HR: 0.82; 95% CI: 0.68, 0.99). Among advanced-stage NSCLC patients who received immunotherapy, NH-Black patients experienced higher survival compared with NH-White patients. We urge the implementation of policies and interventions that seek to equalize access to care as a means of addressing differences in overall NSCLC survival by race.
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13
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Kanas G, Ge W, Quek RGW, Keeven K, Nersesyan K, Jon E Arnason. Epidemiology of diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL) in the United States and Western Europe: population-level projections for 2020-2025. Leuk Lymphoma 2021; 63:54-63. [PMID: 34510995 DOI: 10.1080/10428194.2021.1975188] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL) treatments have been rapidly evolving for patients treated in later lines of therapy (LoT). Country-specific cancer registry data for the US and Western Europe (WE) were combined with physician survey results to project the incidence, prevalence, and number of DLBCL and FL patients eligible for and treated by LoT between 2020 and 2025. The total number of incidents and prevalent cases of DLBCL and FL is expected to increase between 2020 and 2025 in the US and WE. 56% and 53% of the third line plus (3L+) eligible DLBCL patients and 60% and 55% of eligible FL patients initiated treatment in the US and WE, respectively. Further research is warranted to understand the reasons behind the high proportion of treatment eligible patients who do not initiate treatment, and potential differences between countries, especially in the 3L + settings.
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Affiliation(s)
| | - Wenzhen Ge
- Regeneron Pharmaceuticals Inc. - Health Economics & Outcomes Research, Tarrytown, NY, USA
| | - Ruben G W Quek
- Regeneron Pharmaceuticals Inc. - Health Economics & Outcomes Research, Tarrytown, NY, USA
| | | | | | - Jon E Arnason
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
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14
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Lee SF, Evens AM, Ng AK, Luque-Fernandez MA. Socioeconomic inequalities in treatment and relative survival among patients with diffuse large B-cell lymphoma: a Hong Kong population-based study. Sci Rep 2021; 11:17950. [PMID: 34504223 PMCID: PMC8429768 DOI: 10.1038/s41598-021-97455-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 08/09/2021] [Indexed: 12/24/2022] Open
Abstract
The influence of socioeconomic status (SES) on access to standard chemotherapy and/or monoclonal antibody therapy, and associated secular trends, relative survival, and excess mortality, among diffuse large B-cell lymphoma (DLBCL) patients is not clear. We conducted a Hong Kong population-based cohort study and identified adult patients with histologically diagnosed DLBCL between 2000 and 2018. We examined the association of SES levels with the odds and the secular trends of receipt of chemotherapy and/or rituximab. Additionally, we estimated the long-term relative survival by SES utilizing Hong Kong life tables. Among 4017 patients with DLBCL, 2363 (58.8%) patients received both chemotherapy and rituximab and 740 (18.4%) patients received chemotherapy alone, while 1612 (40.1%) and 914 (22.8%) patients received no rituximab or chemotherapy, respectively. On multivariable analysis, low SES was associated with lesser use of chemotherapy (odd ratio [OR] 0.44; 95% CI 0.34-0.57) and rituximab (OR 0.41; 95% CI 0.32-0.52). The socioeconomic disparity for either treatment showed no secular trend of change. Additionally, patients with low SES showed increased excess mortality, with a hazard ratio of 2.34 (95% CI 1.67-3.28). Improving survival outcomes for patients with DLBCL requires provision of best available medical care and securing access to treatment regardless of patients' SES.
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Affiliation(s)
- Shing Fung Lee
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong, China
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, China
| | - Andrew M Evens
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Miguel-Angel Luque-Fernandez
- Department of Non-Communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, London, UK.
- Department of Non-Communicable Disease and Cancer Epidemiology, Instituto de Investigacion Biosanitaria de Granada (Ibs.GRANADA), University of Granada, Granada, Spain.
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15
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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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16
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Hein DM, Ahn C, Aguilera TA, Folkert MR, Sanford NN. Trends and Factors Associated With Receipt of Upfront Surgery for Stage II to III Rectal Adenocarcinoma in the United States, 2006 to 2016. Am J Clin Oncol 2021; 44:187-194. [PMID: 33710137 DOI: 10.1097/coc.0000000000000808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The German rectal study published in 2004 established neoadjuvant chemoradiation as a standard of care for locally advanced rectal cancer and current National Comprehensive Cancer Network guidelines endorse several preoperative regimens. Upfront surgery, however, is considered substandard care. In the era of evolving treatment paradigms for locally advanced rectal cancer, we sought to assess trends and predictors of receipt of upfront surgery for stage II to III rectal cancer. METHODS The National Cancer Database was used to identify patients diagnosed with clinical stage II to III rectal adenocarcinoma between 2006 and 2016. Multivariable logistic regression defined adjusted odds ratios and associated 95% confidence intervals of receipt of upfront definitive surgery. The timing of upfront surgery relative to day of diagnosis and rate of receipt of adjuvant therapy were also estimated. RESULTS Among 51,562 patients, 6411 (12.4%) were treated with upfront surgery, which decreased from 16.7% in 2006 to 7.1% in 2016 (P<0.001). The majority of patients (5737 [89.5%]) had definitive surgery after initial diagnostic biopsy. Variables associated with receipt of upfront surgery included female sex, older age, higher comorbidity score, and treatment at a community cancer center (P<0.001). Among those receiving upfront surgery, 2904 (45.3%) received adjuvant radiation therapy, 3218 (50.2%) received adjuvant chemotherapy, and 2559 (39.9%) received no further treatment. CONCLUSIONS The proportion of patients with clinical stage II to III rectal cancer treated with upfront surgery has steadily declined since 2006, however, certain subgroups appear to remain at greater risk. Further research is needed to better elucidate patient and systems-level factors contributing to these disparities in care.
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Affiliation(s)
- David M Hein
- Department of Radiation Oncology, University of Texas Southwestern
| | - Chul Ahn
- Department of Clinical Sciences
- Harold Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX
| | - Todd A Aguilera
- Department of Radiation Oncology, University of Texas Southwestern
| | | | - Nina N Sanford
- Department of Radiation Oncology, University of Texas Southwestern
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17
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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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18
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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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19
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Association of insurance disparities and survival in adults with multiple myeloma: A non-concurrent cohort study. Leuk Res 2021; 104:106542. [PMID: 33721572 DOI: 10.1016/j.leukres.2021.106542] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 01/28/2021] [Accepted: 02/16/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Multiple myeloma (MM) accounts for 10 % of all hematological malignancies. As recent advances in MM treatment continue to improve survival rates, socioeconomic barriers need to be identified to ensure equal treatment. This study evaluates the association between insurance status and survival in patients with MM. METHODS This study analyzed patients with MM from the 2007-2016 Surveillance, Epidemiology, and End Results (SEER) Program database. Insurance status was categorized as uninsured, Medicaid, private insurance, and other insurance. Cancer-specific survival was measured at one- and five-years post diagnosis. RESULTS From 2007-2016, there were 41,846 patients with MM extracted from the SEER database. Those with private insurance had a higher proportion of participants that identified as married (65.5 %), resided in metropolitan cities (90.1 %), and identified as white (76 %) and non-Hispanic (90.8 %). The uninsured group had the highest proportion of Black participants compared to other insurance groups (37.4 %). After adjustment for age, sex, race, ethnicity, marital status, and residence, the likelihood of five-year survival was significantly lower in those respondents with Medicaid (adjusted (adj) Hazard Ratio (HR): 1.44; 95 % Confidence Interval (CI): 1.36-1.53), when compared with private insurance holders. Those who were uninsured had a 26 % increased mortality hazard than those with private insurance (95 % CI 1.04-1.53). CONCLUSION After adjustment, insurance status can influence the survival of adults with MM. As treatment modalities for MM continue to advance, the insurance status of a patient should not hinder their ability to receive the most effective and timely therapies.
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Nieto MJ, Li Z, Rehman H, Saif MW. Lower 24-Month Relative Survival among Black Patients with Non- Hodgkin's Lymphoma: An Analysis of the SEER Data 1997-2015. JOURNAL OF CLINICAL HAEMATOLOGY 2021; 2:5-13. [PMID: 33834180 PMCID: PMC8026162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background Recent progress in the therapies used in patients with Non- Hodgkin's lymphoma has improved survival. The incidence has been reported to be decreasing in the last few years, accounting for 4% of all cancers. This study analyzed time trends for incidence, mortality, and prevalence of NHL. Methods We analyzed the SEER Cancer Database from 1997 to 2015. Join point regression analysis was used to determine age-adjusted incidence rates, 24-month relative survival rate, and to identify racial/ethnic groups with a lower survival. Results The trend in incidence of NHL decreased between 2008 and 2011 at an annual percentage change rate of 3.74%. The male predominance among NHL patients between 1997-2015 was 57%. The number of male patients affected with NHL has been similar in the last 20 years. Female predominance with NHL was higher in 1998 at 46 %, and lower in 2010 at 42.85%. The 24-month relative survival rate was higher among white patients as compared to black patients with NHL. Conclusions Our analysis demonstrated that the incidence of Non-Hodgkin's Lymphoma has decreased among minorities; however, the outcomes are inferior in terms of survival. This analysis showed an inferior 24-month relative survival rate among black patients compared with white patients. This analysis demonstrates the need for further research in NHL to determine the biological differences and social factors that influence the lower survival among black patients with NHL.
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Affiliation(s)
- Maria J Nieto
- Northwell Health Cancer Institute & Donald and Barbara
Zucker School of Medicine at Hofstra, Lake Success, NY, USA,Correspondence should be addressed to Maria J
Nieto;
| | - Zhen Li
- Wyckoff Medical Center, New York, NY, USA
| | - Hasan Rehman
- Northwell Health Cancer Institute & Donald and Barbara
Zucker School of Medicine at Hofstra, Lake Success, NY, USA
| | - Muhammad Wasif Saif
- Northwell Health Cancer Institute & Donald and Barbara
Zucker School of Medicine at Hofstra, Lake Success, NY, USA
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Analysis of Heterogeneity in Survival Benefit of Immunotherapy in Oncology According to Patient Demographics and Performance Status: A Systematic Review and Meta-Analysis of Overall Survival Data. Am J Clin Oncol 2020; 43:193-202. [PMID: 31809328 DOI: 10.1097/coc.0000000000000650] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Immunotherapy (IO) has become standard of care (SOC) for many advanced malignancies, although identifying patients likely to benefit remains difficult. We sought to assess whether demographic factors are associated with response to IO, compared with SOC systemic therapy, using stratified meta-analysis. METHODS A systematic review of MEDLINE, PubMed, Embase, and Scopus from inception to October 2, 2018. Randomized controlled trials comparing IO to SOC in patients with advanced solid organ malignancies were included if results were stratified by age, performance status (PS), or race, assessing overall survival (OS). Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for each group using random-effects models independently. RESULTS We identified 21 eligible randomized controlled trials, including 20 stratified by age, 17 by PS, and 4 by race. Patients with PS 0 (HR, 0.74; 95% CI, 0.63-0.86) and PS≥1 (HR, 0.75; 95% CI, 0.68-0.83) had similar OS benefits from IO compared with SOC (P=0.80). There was no difference on the basis of patient race (white vs. nonwhite) (P=0.46). IO demonstrated an OS benefit for younger (below 65 y: HR, 0.73; 95% CI, 0.65-0.82) and older (65 y and above: HR, 0.79; 95% CI, 0.71-0.88) patients with no difference between age groups (P=0.27). Among prespecified subgroup analyses, there was significant effect modification in 2 subgroups: younger patients in the first-line setting (P=0.03) and those receiving anti-CTLA-4 drugs (P=0.05). CONCLUSIONS When examining OS using stratified meta-analysis, we did not demonstrate significant differences in IO efficacy according to patient age, PS or race, though data on race were sparse.
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Wang X, Ojha RP, Partap S, Johnson KJ. The effect of insurance status on overall survival among children and adolescents with cancer. Int J Epidemiol 2020; 49:1366-1377. [DOI: 10.1093/ije/dyaa079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2020] [Indexed: 12/11/2022] Open
Abstract
Abstract
Background
Differences in access, delivery and utilisation of health care may impact childhood and adolescent cancer survival. We evaluated whether insurance coverage impacts survival among US children and adolescents with cancer diagnoses, overall and by age group, and explored potential mechanisms.
Methods
Data from 58 421 children (aged ≤14 years) and adolescents (15–19 years), diagnosed with cancer from 2004 to 2010, were obtained from the National Cancer Database. We examined associations between insurance status at initial diagnosis or treatment and diagnosis stage; any treatment received; and mortality using logistic regression, Cox proportional hazards (PH) regression, restricted mean survival time (RMST) and mediation analyses.
Results
Relative to privately insured individuals, the hazard of death (all-cause) was increased and survival months were decreased in those with Medicaid [hazard ratio (HR) = 1.27, 95% confidence interval (CI): 1.22 to 1.33; and −1.73 months, 95% CI: −2.07 to −1.38] and no insurance (HR = 1.32, 95% CI: 1.20 to 1.46; and −2.13 months, 95% CI: −2.91 to −1.34). The HR for Medicaid vs. private insurance was larger (pinteraction <0.001) in adolescents (HR = 1.52, 95% CI: 1.41 to 1.64) than children (HR = 1.16, 95% CI: 1.10 to 1.23). Despite statistical evidence of PH assumption violation, RMST results supported all interpretations. Earlier diagnosis for staged cancers in the Medicaid and uninsured populations accounted for an estimated 13% and 19% of the survival deficit, respectively, vs. the privately insured population. Any treatment received did not account for insurance-associated survival differences in children and adolescents with cancer.
Conclusions
Children and adolescents without private insurance had a higher risk of death and shorter survival within 5 years following cancer diagnosis. Additional research is needed to understand underlying mechanisms.
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Affiliation(s)
- Xiaoyan Wang
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Rohit P Ojha
- Center for Outcomes Research, JPS Health Network, Fort Worth, TX, USA
- Department of Biostatistics and Epidemiology, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Sonia Partap
- Department of Neurology, Stanford University, Palo Alto, CA, USA
- Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Kimberly J Johnson
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
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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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Xie Y, Jia M, Shi J, Tao Y. Inferior prognosis of gastric involvement in patients with gastrointestinal Burkitt Lymphoma. Cancer Med 2020; 9:3107-3114. [PMID: 32160410 PMCID: PMC7196052 DOI: 10.1002/cam4.2975] [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: 09/05/2019] [Revised: 01/30/2020] [Accepted: 02/22/2020] [Indexed: 12/15/2022] Open
Abstract
Due to limited information reported on the clinical characteristics and outcomes of Burkitt lymphoma (BL) patients with gastrointestinal (GI) involvement, here we used the Surveillance, Epidemiology, and End Results (SEER) database to perform our study in a population‐based scale. Extranodal GI involvement was categorized into gastric and intestinal primary sites. A total of 477 BL patients with GI involvement extracted from the SEER database between 2004 and 2015 were included in this study, 112 (23.5%) with the stomach and 365 (76.5%) with the intestine. Our study demonstrated that gastric involvement, older age, male gender, black race, advanced‐stage III/IV, no‐chemotherapy, and earlier years of diagnosis were associated with a significantly worse overall survival (OS) in GI BL patients after adjustment in multivariate analysis, whereas marital status did not significantly influence OS. Notably, BL Patients with gastric involvement had a significantly inferior 5‐year OS in both univariate and multivariate analysis, as compared to those with intestinal involvement (37.8% vs. 70.2%; Univariate: HR = 2.637, P < .001; Multivariate: HR = 1.489, P = .016). In subgroup analysis, we demonstrated that gastric BL patients had a consistently worse OS than intestinal patients regardless of gender, clinical stage and year of diagnosis. Hopefully, with the advances in modern therapy, improved survival has been found in BL patients with GI involvement as a whole, specifically those with gastric involvement (HR = 0.529, P = .011) in recent years of diagnosis. In conclusion, despite the improved survival achieved in recent years, the prognosis of BL patients with gastric involvement is still poor. Novel personalized therapies and better access to intensive care remain to be needed.
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Affiliation(s)
- Yi Xie
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Mengyu Jia
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jumei Shi
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yi Tao
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
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Cook BL, Wang Y, Sonik R, Busch S, Carson N, Progovac AM, Zaslavsky AM. Assessing provider and racial/ethnic variation in response to the FDA antidepressant box warning. Health Serv Res 2020; 54 Suppl 1:255-262. [PMID: 30666633 PMCID: PMC6341210 DOI: 10.1111/1475-6773.13104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION After the 2004 FDA box warning raised concerns about increased suicidal ideation among youth taking antidepressants, antidepressant use decreased for White youth but slightly increased for Black and Latino youth. Better understanding of patient and provider factors contributing to these differences is needed to improve future risk warning dissemination. METHODS We analyzed antidepressant prescriptions for youth aged 5-17 in 2002-2006 Medicaid claims data from four states (CA, FL, NC, and NY). In multilevel models, we assessed provider- and patient-level contributions to changes in antidepressant use by race/ethnicity and compared responses to the box warning between providers with large (>2/3) and small (<1/3) proportions of minority patients. RESULTS A significant amount of variance in overall prescribing patterns (calculated by the ICC) was explained at the provider level. Significant provider-level variation was also identified in the differential effect of the box warning by racial/ethnic group. In a test of the influence of provider panel mix, we found that providers with large proportions of minority patients reduced antidepressant prescribing more slowly after the box warning than other providers. DISCUSSION This study is the first to assess provider- and patient-level variation in the impact of a health care policy change on treatment disparities. Black and Latino youth Medicaid beneficiaries were seen by largely different providers than their White counterparts, and these distinct providers were influential in driving antidepressant prescription patterns following the box warning. Concerted outreach to providers of minority beneficiaries is needed to ensure that risk warnings and clinical innovations diffuse swiftly across racial/ethnic minority groups.
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Affiliation(s)
- Benjamin L Cook
- Health Equity Research Lab, Cambridge Health Alliance, Harvard Medical School, Cambridge, Massachusetts
| | - Ye Wang
- Disparities Research Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Rajan Sonik
- Tucker-Seeley Research Lab, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California
| | - Susan Busch
- Yale School of Public Health, New Haven, Connecticut
| | - Nicholas Carson
- Health Equity Research Lab, Cambridge Health Alliance, Harvard Medical School, Cambridge, Massachusetts
| | - Ana M Progovac
- Health Equity Research Lab, Cambridge Health Alliance, Harvard Medical School, Cambridge, Massachusetts
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Goldstein JS, Switchenko JM, Behera M, Flowers CR, Koff JL. Insurance status impacts overall survival in Burkitt lymphoma. Leuk Lymphoma 2019; 60:3225-3234. [PMID: 31274033 PMCID: PMC6923579 DOI: 10.1080/10428194.2019.1623884] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/16/2019] [Accepted: 05/15/2019] [Indexed: 12/11/2022]
Abstract
The impact of insurance status on clinical outcomes in Burkitt (BL) and plasmablastic (PBL) lymphomas remains unknown. We used the National Cancer Database to examine insurance status' effect on overall survival (OS) in adults diagnosed with these lymphomas between 2004 and 2014. BL patients with private insurance had significantly better OS compared to those without. In patients aged <65 years, hazard ratios were 1.4 for uninsured status (95% confidence interval 1.2-1.7), 1.2 for Medicaid (95% CI 1.0-1.4), and 1.5 for Medicare (95% CI 1.2-1.9). For patients aged >65 years, hazard ratio for uninsured status was 8.4 (95% CI 2.5-28.3). Conversely, underinsured PBL patients experienced no difference in OS. Thus, expanding insurance-related access to care may improve survival in BL, for which curative therapy exists, but not PBL, where more effective therapies are needed. Our findings add to mounting evidence that adequate health insurance is particularly important for patients with curable cancers.
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Affiliation(s)
| | - Jeffrey M. Switchenko
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Madhusmita Behera
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Christopher R. Flowers
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Jean L. Koff
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
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27
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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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Shah NN, Xi Y, Liu Y, Koff JL, Flowers CR, Behera M, Cohen JB. Racial and Socioeconomic Disparities in Mantle Cell Lymphoma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:e312-e320. [PMID: 31029647 DOI: 10.1016/j.clml.2019.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/21/2019] [Accepted: 03/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although race and socioeconomic factors are associated with outcome in many malignancies, few studies have examined the effect of race and socioeconomic status on patients with mantle cell lymphoma (MCL). PATIENTS AND METHODS We used the National Cancer Database to identify patients with MCL diagnosed between 2004 and 2013. We used χ2 and analysis of variance to assess associations of covariates with race/ethnicity. For univariate and multivariable analyses of overall survival (OS) we used Cox proportional hazards models. OS from the time of diagnosis was the primary end point. RESULTS Of 18,120 MCL patients, 14,984 (83%) were white non-Hispanic (NH), 709 (4%) black NH, and 1096 (6%) Hispanic. Of these patients, 6798 (39%) had private insurance, 9520 (55%) Medicare, and 635 (4%) Medicaid. Compared with white NH race, black race was associated with treatment at an academic/research program (347 of 681 patients [51%] vs. 5577 of 14,851 [38%]), B symptoms (196 patients [28%] vs. 3 [25%]), Medicaid/uninsured status (101 patients [15%] vs. 642 [5%]), and residence in regions with lower average education and income (all P < .001). Compared with NH black and Hispanic patients, more white NH patients received stem cell transplantation (73 patients [10%] vs. 114 [10%] vs. 1891 [13%]; P < .001). In multivariable analysis, Hispanic ethnicity, private insurance, and treatment at an academic center were associated with better OS (5-year OS 55.8%, 66.2%, and 56.6%, respectively), whereas black race was associated with inferior OS (5-year OS 46.8%). CONCLUSION We identified disparities according to race and ethnicity in OS, independent of insurance and socioeconomic status. Further assessment of treatment patterns might elucidate new targets for improving access to care and health outcomes for rare cancers.
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Affiliation(s)
- Nikesh N Shah
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Yizhao Xi
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Yuan Liu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jean L Koff
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Christopher R Flowers
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Madhusmita Behera
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Jonathon B Cohen
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
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Goldstein JS, Nastoupil LJ, Han X, Jemal A, Ward E, Flowers CR. Disparities in survival by insurance status in follicular lymphoma. Blood 2018; 132:1159-1166. [PMID: 30042094 PMCID: PMC6137560 DOI: 10.1182/blood-2018-03-839035] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/06/2018] [Indexed: 01/07/2023] Open
Abstract
Follicular lymphoma (FL) is the second most common non-Hodgkin lymphoma and most common indolent non-Hodgkin lymphoma. Lower socioeconomic status is associated with poor outcomes in FL, suggesting that access to care is an important prognostic factor; however, the association between insurance status and FL survival has not been sufficiently examined. The National Cancer Database, a nationwide cancer registry, was used to evaluate 43 648 patients with FL diagnosed between 2004 and 2014. All analyses were performed on 2 cohorts segmented at age 65 years to account for changes in insurance status with Medicare eligibility. Cox proportional hazard models calculated hazard ratios (HRs) with confidence intervals (CIs) for the association between insurance status and overall survival (OS) controlling for the available sociodemographic and prognostic factors. Kaplan-Meier curves display outcomes by insurance status for patients covered by private insurance, no insurance, Medicaid, or Medicare. When compared with patients younger than age 65 years with private insurance, patients younger than age 65 years with no insurance (HR, 1.96; 95% CI, 1.69-2.28), with Medicaid (HR, 1.82; 95% CI, 1.57-2.12), and with Medicare (HR, 1.96; 95% CI, 1.71-2.24) had significantly worse OS after adjusting for sociodemographic and prognostic factors. Compared with patients age 65 years or older with private insurance, those with Medicare only (HR, 1.28; 95% CI, 1.17-1.4) had significantly worse OS. For adults with FL, expanding access to care through insurance has the potential to improve outcomes.
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Babu SM, Garg S, Kanakasetty GB, Kuntegowdanahalli LC, Dasappa L, Rao SA. Diffuse large B-cell lymphoma: A retrospective study from a regional care center in South India. Indian J Cancer 2018; 55:66-69. [PMID: 30147096 DOI: 10.4103/ijc.ijc_450_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Diffuse large B-cell lymphoma (DLBCL) is an aggressive lymphoma whose outcomes have significantly improved with rituximab in addition to anthracycline-based chemotherapy. Objective This study aimed to study the epidemiology, treatment, and outcomes of patients with DLBCL. Materials and Methods A total of 526 patients diagnosed with DLBCL between 2006 and 2015 were retrospectively analyzed. Results The median age was 50 years with a male preponderance. Two hundred and twenty-three (42.39%) patients presented with B symptoms. A total of 53 (10.07%) patients presented with bulky disease and 202 (31.40%) with extranodal disease. The most common extranodal sites involved were the stomach (20.79%) and the bone marrow (10.89%). Bone marrow involvement was seen in only 22 (4.18%) cases. The distribution of patients presenting in low, low-intermediate, high-intermediate, and high-risk International Prognostic Index (IPI) were 148 (28.13%), 191 (36.31%), 124 (23.57%), and 63 (11.97%), respectively. The median survival of the entire cohort was 22 months. Survival of patients that compared the two groups with respect to the IPI - one having clubbed patients in low and low/intermediate risk and the other clubbing high/intermediate and high risk showed significantly improved survival in the lower risk groups - 24 versus 18 months (P = 0). The survival of those who received chemoimmunotherapy i.e R - CHOP was significantly better than those who received chemotherapy (CHOP) alone - 33 versus 21 months (P = 2.22e-16). Conclusions DLBCL is one of the most common lymphomas seen in our daily practice. Outcomes are significantly inferior compared to western countries. Biological and patient-related factors such as nongerminal center B subtype, higher extranodal involvement, and poor tolerability to treatment could contribute to inferior outcomes.
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Affiliation(s)
- Suresh Mc Babu
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Sunny Garg
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Govinda Babu Kanakasetty
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | | | - Lokanatha Dasappa
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Suparna Ajit Rao
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
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Treatment Patterns Among Women Diagnosed With Stage I-III Triple-negative Breast Cancer. Am J Clin Oncol 2017; 41:997-1007. [PMID: 29278527 DOI: 10.1097/coc.0000000000000418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine contemporary treatment patterns for women diagnosed with stage I-III triple-negative breast cancer (TNBC) in the United States. METHODS We identified 48,961 patients diagnosed with stage I-III TNBC from 2010 to 2013 in the National Cancer Data Base and created 3 treatment subcohorts (definitive locoregional therapy [appropriate local therapy, including surgery/radiation], adjuvant chemotherapy [stage II-III disease or stage I tumors with tumor size ≥1 cm], and adjuvant chemotherapy for small tumors [stage I tumors with tumor size <1 cm and node negative]). We performed descriptive analyses, calculated percentages for treatment receipt, and used multivariable modified Poisson regression models to estimate risk ratios (RRs) with 95% confidence intervals (CIs) predicting receipt of treatments. RESULTS Older age, larger tumor size, positive nodal status, and Southern/Pacific US regions, but not race/ethnicity, were strongly associated with a lower probability of receiving definitive locoregional therapy. Older age was also strongly associated with lower likelihood of adjuvant chemotherapy receipt, as were grade, negative nodal status, and higher comorbidity. For example, compared with women aged 18 to 39 years, those aged 75 to 90 years were 17% less likely to receive definitive locoregional therapy (RR, 0.83; 95% CI, 0.73-0.88), and 62% less likely to receive adjuvant chemotherapy (RR, 0.38; 95% CI, 0.35-0.41). Age, tumor grade, tumor size, and comorbidity score were also independently associated with receipt of chemotherapy for women with small TNBC. CONCLUSIONS Advancing age but not race/ethnicity was associated with lower likelihood of recommended treatment receipt among women with TNBC. Although omission of therapy among older patients with breast cancer may be appropriate in the case of smaller and lower risk TNBC, some were likely undertreated.
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Kirtane K, Lee SJ. Racial and ethnic disparities in hematologic malignancies. Blood 2017; 130:1699-1705. [PMID: 28724539 PMCID: PMC5639484 DOI: 10.1182/blood-2017-04-778225] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/08/2017] [Indexed: 01/05/2023] Open
Abstract
Racial and ethnic disparities in patients with solid malignancies have been well documented. Less is known about these disparities in patients with hematologic malignancies. With the advent of novel chemotherapeutics and targeted molecular, cellular, and immunologic therapies, it is important to identify differences in care that may lead to disparate outcomes. This review provides a critical appraisal of the empirical research on racial and ethnic disparities in incidence, survival, and outcomes in patients with hematologic malignancies. The review focuses on patients with acute myeloid leukemia, acute lymphocytic leukemia, multiple myeloma, non-Hodgkin lymphoma, Hodgkin lymphoma, myeloproliferative neoplasms, and myelodysplastic syndrome. The review discusses possible causes of racial and ethnic disparities and also considers future directions for studies to help decrease disparities.
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Affiliation(s)
- Kedar Kirtane
- Division of Medical Oncology, University of Washington, Seattle, WA; and
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Stephanie J Lee
- Division of Medical Oncology, University of Washington, Seattle, WA; and
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
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Koff JL, Flowers CR. Prognostic modeling in diffuse large B-cell lymphoma in the era of immunochemotherapy: Where do we go from here? Cancer 2017; 123:3222-3225. [PMID: 28464215 PMCID: PMC5738913 DOI: 10.1002/cncr.30740] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/13/2017] [Indexed: 01/15/2023]
Abstract
The model and approach described by Howlader et al could form a foundation for future risk‐prediction models that incorporate data on known differences in demographic, socioeconomic, clinical, and biological factors. Data from large diffuse large B‐cell lymphoma patient cohorts that capture host and tumor genomics and known clinical prognostic factors will be necessary to provide the resources for constructing meaningful prognostic models and to establish prediction models that will allow us to limit therapy and therapy‐related toxicity for favorable subsets of patients while optimizing directed approaches for poor‐risk subsets.See also pages 3326‐34.
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Affiliation(s)
- Jean L. Koff
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University Atlanta, GA, USA
| | - Christopher R. Flowers
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University Atlanta, GA, USA
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Caram ME, Borza T, Min HS, Griggs JJ, Miller DC, Hollenbeck BK, Mukherjee B, Skolarus TA. Early National Dissemination of Abiraterone and Enzalutamide for Advanced Prostate Cancer in Medicare Part D. J Oncol Pract 2017; 13:e694-e702. [PMID: 28628393 PMCID: PMC5555032 DOI: 10.1200/jop.2016.020206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Abiraterone and enzalutamide were approved by the Food and Drug Administration in 2011 and 2012 to treat men with metastatic castration-resistant prostate cancer (mCRPC). Most men with mCRPC are > 65 years of age and thus eligible for Medicare Part D. We conducted a study to better understand the early dissemination of these drugs across the United States using national Medicare Part D data. METHODS We evaluated the number of prescriptions for abiraterone and enzalutamide by provider specialty and hospital referral region (HRR) using Medicare Part D and Dartmouth Atlas data. We categorized HRRs by abiraterone and enzalutamide prescriptions, adjusted for prostate cancer incidence, and examined factors associated with regional variation using multilevel regression models. RESULTS Among providers who wrote the majority of prescriptions for abiraterone or enzalutamide in 2013 (n = 2,121), 87.5% were medical oncologists, 3.3% were urologists, and 9.2% were other provider specialties. Among prescribers, approximately 30% were responsible for three quarters of the claims for abiraterone and 20% were responsible for more than half the claims for enzalutamide. Some HRRs demonstrated low-prescribing rates despite average medical oncology and urology physician workforce density. Our multilevel model demonstrated that regional factors potentially influenced variation in care. CONCLUSION The majority of prescriptions written for abiraterone and enzalutamide through Medicare Part D in 2013 were written by a minority of providers, with marked regional variation across the United States. Better understanding of the early national dissemination of these effective but expensive drugs can help inform strategies to optimize introduction of new, evidence-based mCRPC treatments.
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Affiliation(s)
- Megan E.V. Caram
- University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Tudor Borza
- University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Hye-Sung Min
- University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jennifer J. Griggs
- University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - David C. Miller
- University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Bhramar Mukherjee
- University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Ted A. Skolarus
- University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, MI
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Tao L, Clarke CA, Rosenberg AS, Advani RH, Jonas BA, Flowers CR, Keegan THM. Subsequent primary malignancies after diffuse large B-cell lymphoma in the modern treatment era. Br J Haematol 2017; 178:72-80. [PMID: 28542862 PMCID: PMC5487277 DOI: 10.1111/bjh.14638] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 12/22/2016] [Indexed: 01/07/2023]
Abstract
With the addition of rituximab and other treatment advances, survival after diffuse large B-cell lymphoma (DLBCL) has improved, but subsequent primary malignancies (SPMs) have emerged as an important challenge for DLBCL survivorship. We calculated standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) for SPMs among 23 879 patients who survived at least 1 year after a first primary DLBCL diagnosed during 1989-2012, compared to the general population in California. Cumulative incidence (CMI) of SPMs, accounting for the competing risk of death, also was calculated. We found that the incidence of acute myeloid leukaemia (AML) nearly doubled in the post-rituximab era [SIR (95% CI) 4·39 (2·51-7·13) pre- (1989-2000) and 8·70 (6·62-11·22) post-rituximab (2001-2012)]. Subsequent thyroid cancer was rare pre-rituximab, but increased substantially after 2001 [0·66 (0·08-2·37) vs. 2·27(1·44-3·41)]. The 5-year CMI for all SPMs (4·77% pre- vs. 5·41% post-rituximab, P = 0·047), AML (0·15% vs. 0·41%, P = 0·003), thyroid cancer (0·03% vs. 0·15%, P = 0·003) and melanoma (0·25% vs. 0·42%, P = 0·020) were greater in DLBCL patients diagnosed in the post- versus pre-rituximab period. This study provides insight into the changing pattern of SPM occurrence after the introduction of rituximab, which may elucidate the aetiology of SPMs and should guide future cancer surveillance efforts among DLBCL patients.
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MESH Headings
- Adolescent
- Adult
- Aged
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/therapeutic use
- California/epidemiology
- Female
- Follow-Up Studies
- Humans
- Incidence
- Leukemia, Myeloid, Acute/chemically induced
- Leukemia, Myeloid, Acute/epidemiology
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/epidemiology
- Male
- Melanoma/chemically induced
- Melanoma/epidemiology
- Middle Aged
- Neoplasms, Second Primary/chemically induced
- Neoplasms, Second Primary/epidemiology
- Registries
- Rituximab/adverse effects
- Rituximab/therapeutic use
- Thyroid Neoplasms/chemically induced
- Thyroid Neoplasms/epidemiology
- Young Adult
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Affiliation(s)
- Li Tao
- Cancer Prevention Institute of California, Fremont, CA, USA
| | - Christina A Clarke
- Cancer Prevention Institute of California, Fremont, CA, USA
- Department of Health Research and Policy (Epidemiology), Stanford University School of Medicine, Stanford, CA, USA
| | - Aaron S Rosenberg
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | | | - Brian A Jonas
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Christopher R Flowers
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Theresa H M Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
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Boslooper K, Hoogendoorn M, van Roon EN, Kibbelaar RE, Storm H, Hovenga S, Woolthuis G, van Rees BP, Klijs B, Veeger NJ, Kluin-Nelemans HC, de Bock GH. No outcome disparities in patients with diffuse large B-cell lymphoma and a low socioeconomic status. Cancer Epidemiol 2017; 48:110-116. [DOI: 10.1016/j.canep.2017.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/22/2017] [Accepted: 04/18/2017] [Indexed: 10/19/2022]
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Bulka C, Nastoupil LJ, Koff JL, Bernal-Mizrachi L, Ward KC, Williams JN, Bayakly AR, Switchenko JM, Waller LA, Flowers CR. Relations Between Residential Proximity to EPA-Designated Toxic Release Sites and Diffuse Large B-Cell Lymphoma Incidence. South Med J 2017; 109:606-614. [PMID: 27706495 DOI: 10.14423/smj.0000000000000545] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Examining the spatial patterns of diffuse large B-cell lymphoma (DLBCL) incidence and residential proximity to toxic release locations may provide insight regarding environmental and sociodemographic risk factors. METHODS We linked and geocoded cancer incidence data for the period 1999-2008 from the Georgia Comprehensive Cancer Registry with population data from the US Census and the Environmental Protection Agency's Toxics Release Inventory. We conducted cluster analyses and constructed Poisson regression models to assess DLBCL incidence as a function of mean distance to the toxic release sites. RESULTS In total, 3851 incident DLBCL cases occurred among adults residing in Georgia between 1999 and 2008. Significant focal clustering was observed around 57% of ethylene oxide sites, 5% of benzene sites, 9% of tetrachloroethylene sites, 7% of styrene sites, 10% of formaldehyde sites, 5% of trichloroethylene sites, and 10% of all release sites. Mean distance to sites was significantly associated with DLBCL risk for all chemicals. CONCLUSIONS Proximity to Toxics Release Inventory sites can be linked to increased DLBCL risk as assessed through focal clustering and Poisson regression, and confirmatory studies using geospatial mapping can aid in further specifying risk factors for DLBCL.
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Affiliation(s)
- Catherine Bulka
- From the Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, the University of Texas MD Anderson Cancer Center, Houston, the Departments of Hematology and Oncology and Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, and the Departments of Epidemiology and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, and the Georgia Department of Public Health, Atlanta
| | - Loretta J Nastoupil
- From the Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, the University of Texas MD Anderson Cancer Center, Houston, the Departments of Hematology and Oncology and Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, and the Departments of Epidemiology and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, and the Georgia Department of Public Health, Atlanta
| | - Jean L Koff
- From the Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, the University of Texas MD Anderson Cancer Center, Houston, the Departments of Hematology and Oncology and Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, and the Departments of Epidemiology and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, and the Georgia Department of Public Health, Atlanta
| | - Leon Bernal-Mizrachi
- From the Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, the University of Texas MD Anderson Cancer Center, Houston, the Departments of Hematology and Oncology and Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, and the Departments of Epidemiology and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, and the Georgia Department of Public Health, Atlanta
| | - Kevin C Ward
- From the Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, the University of Texas MD Anderson Cancer Center, Houston, the Departments of Hematology and Oncology and Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, and the Departments of Epidemiology and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, and the Georgia Department of Public Health, Atlanta
| | - Jessica N Williams
- From the Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, the University of Texas MD Anderson Cancer Center, Houston, the Departments of Hematology and Oncology and Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, and the Departments of Epidemiology and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, and the Georgia Department of Public Health, Atlanta
| | - A Rana Bayakly
- From the Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, the University of Texas MD Anderson Cancer Center, Houston, the Departments of Hematology and Oncology and Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, and the Departments of Epidemiology and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, and the Georgia Department of Public Health, Atlanta
| | - Jeffrey M Switchenko
- From the Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, the University of Texas MD Anderson Cancer Center, Houston, the Departments of Hematology and Oncology and Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, and the Departments of Epidemiology and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, and the Georgia Department of Public Health, Atlanta
| | - Lance A Waller
- From the Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, the University of Texas MD Anderson Cancer Center, Houston, the Departments of Hematology and Oncology and Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, and the Departments of Epidemiology and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, and the Georgia Department of Public Health, Atlanta
| | - Christopher R Flowers
- From the Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, the University of Texas MD Anderson Cancer Center, Houston, the Departments of Hematology and Oncology and Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, and the Departments of Epidemiology and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, and the Georgia Department of Public Health, Atlanta
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Lee H, Park HJ, Park EH, Ju HY, Oh CM, Kong HJ, Jung KW, Park BK, Lee E, Eom HS, Won YJ. Nationwide Statistical Analysis of Lymphoid Malignancies in Korea. Cancer Res Treat 2017; 50:222-238. [PMID: 28361523 PMCID: PMC5784621 DOI: 10.4143/crt.2017.093] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 03/20/2017] [Indexed: 01/06/2023] Open
Abstract
Purpose Regional differences in the incidence of lymphoid malignancies have been reported worldwide, but there has been no large-scale epidemiologic analysis in Korea. The aim of this study was to provide a nationwide population-based statistical analysis of Korean patients with lymphoid malignancies. Materials and Methods The Korea Central Cancer Registry analyzed the incidence and survival of patients with lymphoid malignancies from the Korean National Cancer Incidence Database. Diseases were grouped by clinically relevant categories based on the 2008 World Health Organization classification. Results Overall 65,948 lymphoid diseases were identified between 1999 and 2012. The incidence of most subtypes increased with age, except for precursor cell neoplasms. Male predominance (male:female ratio=1.28:1) was observed. In 2012, annual age-standardized incidence rates per 100,000 persons of Hodgkin’s lymphoma, mature B-cell neoplasm, mature T/natural killer (NK)–cell neoplasm, and precursor cell neoplasm were 0.46, 6.60, 0.95, and 1.50, respectively, and they increased yearly from 1999. Composite Hodgkin’s and non-Hodgkin’s lymphomas were extremely rare. Survival improvement estimated using 5-year relative survival rate was observed in patients with Hodgkin’s lymphoma (71.1%-83.0%), diffuse large B-cell lymphoma (49.5%-61.5%), plasma cell neoplasms (20.2%-36.9%), and lymphoblastic lymphoma/leukemia (41.5%-56.3%) between 1993 and 2012. However, survival rates of T/NK-cell lymphoma (excluding cutaneous T-cell lymphoma) ranged from 40.5%-43.5% during the study period. Survival rates decreased with age in most subtypes. Conclusion This report presented the subtype-specific statistical analysis of lymphoid malignancies in the Korean population, showing increasing incidences and survival rates in most subtypes.
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Affiliation(s)
- Hyewon Lee
- Center for Hematologic Malignancy, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hyeon Jin Park
- Center for Pediatric Oncology, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Eun-Hye Park
- Cancer Registration and Statistics Branch, National Cancer Center, Goyang, Korea
| | - Hee Young Ju
- Center for Pediatric Oncology, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chang-Mo Oh
- Cancer Registration and Statistics Branch, National Cancer Center, Goyang, Korea
| | - Hyun-Joo Kong
- Cancer Registration and Statistics Branch, National Cancer Center, Goyang, Korea
| | - Kyu-Won Jung
- Cancer Registration and Statistics Branch, National Cancer Center, Goyang, Korea
| | - Byung-Kiu Park
- Center for Pediatric Oncology, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Eunyoung Lee
- Center for Hematologic Malignancy, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hyeon-Seok Eom
- Center for Hematologic Malignancy, Research Institute and Hospital, National Cancer Center, Goyang, Korea.,Department of System Cancer Science Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Young-Joo Won
- Cancer Registration and Statistics Branch, National Cancer Center, Goyang, Korea.,Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
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Le Guyader-Peyrou S, Orazio S, Dejardin O, Maynadié M, Troussard X, Monnereau A. Factors related to the relative survival of patients with diffuse large B-cell lymphoma in a population-based study in France: does socio-economic status have a role? Haematologica 2016; 102:584-592. [PMID: 27909221 PMCID: PMC5394966 DOI: 10.3324/haematol.2016.152918] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 11/24/2016] [Indexed: 12/24/2022] Open
Abstract
The survival of patients with diffuse large B-cell lymphoma has increased during the last decade as a result of addition of anti-CD20 to anthracycline-based chemotherapy. Although the trend is encouraging, there are persistent differences in survival within and between the USA and European countries suggesting that non-biological factors play a role. Our aim was to investigate the influence of such factors on relative survival of patients with diffuse large B-cell lymphoma. We conducted a retrospective, multicenter, registry-based study in France on 1165 incident cases of diffuse large B-cell lymphoma between 2002 and 2008. Relative survival analyses were performed and missing data were controlled with the multiple imputation method. In a multivariate analysis, adjusted for age, sex and International Prognostic Index, we confirmed that time period was associated with a better 5-year relative survival. The registry area, the medical specialty of the care department (onco-hematology versus other), the time to travel to the nearest teaching hospital, the place of treatment (teaching versus not-teaching hospital -borderline significance), a comorbidity burden and marital status were independently associated with the 5-year relative survival. Adjusted for first-course treatment, inclusion in a clinical trial and treatment discussion in a multidisciplinary meeting were strongly associated with a better survival outcome. In contrast, socio-economic status (determined using the European Deprivation Index) was not associated with outcome. Despite therapeutic advances, various non-biological factors affected the relative survival of patients with diffuse large B-cell lymphoma. The notion of lymphoma-specific expertise seems to be essential to achieve optimal care management and reopens the debate regarding centralization of these patients’ care in hematology/oncology departments.
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Affiliation(s)
- Sandra Le Guyader-Peyrou
- Registre des Hémopathies Malignes de la Gironde, Institut Bergonie, Bordeaux, France .,University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team EPICENE, UMR 1219, F-33000, France
| | - Sébastien Orazio
- Registre des Hémopathies Malignes de la Gironde, Institut Bergonie, Bordeaux, France.,University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team EPICENE, UMR 1219, F-33000, France
| | - Olivier Dejardin
- University Hospital of Caen, U1086 INSERM UCBN «Cancers & Préventions», France
| | - Marc Maynadié
- Registre des Hémopathies Malignes de Côte d'Or, EA4184, Université de Bourgogne, Dijon, France
| | - Xavier Troussard
- Registre des Hémopathies Malignes de Basse Normandie, Caen, France.,Laboratoire d'Hématologie, CHU de Caen, France
| | - Alain Monnereau
- Registre des Hémopathies Malignes de la Gironde, Institut Bergonie, Bordeaux, France.,University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team EPICENE, UMR 1219, F-33000, France
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Fedewa SA, Jemal A, Chen AY. Trends and Predictors of Chemotherapy Use among Thyroid Cancer Patients in the National Cancer Database (2004-2013). Eur Thyroid J 2016; 5:268-276. [PMID: 28101492 PMCID: PMC5216190 DOI: 10.1159/000449379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 08/23/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM Beginning in 2011, the Food and Drug Administration (FDA) approved the use of multikinase inhibitors (MKIs) for medullary thyroid cancers (MTCs), and in 2013 MKIs were approved for metastatic differentiated thyroid cancers (DTCs). However, little is known about the use of chemotherapy in thyroid cancer patients. Thus, the goal of our study was to describe patterns of chemotherapy use, including MKIs, among DTC and MTC patients in the National Cancer Database (NCDB). METHODS Chemotherapy use, along with other treatment types (surgery and radiation), was assessed between 2004 and 2013. The primary predictor was the year of diagnosis (2004-2010 and 2011-2013), based on the FDA's approval of chemotherapy for MTC (2011). Baseline use of MKIs in DTCs in 2013 was also examined. Multivariable logistic regression was used to estimate odds ratios (OR) and 95% CI of receipt of chemotherapy. RESULTS Overall, 199,654 patients were included in our analytic sample with 194,667 nonmetastatic DTCs, 1,633 metastatic DTCs, and 3,354 MTCs. Among MTCs, chemotherapy use significantly increased from 3.1% in 2004-2010 to 5.0% in 2011-2013 (p = 0.018) in unadjusted and adjusted (OR = 1.54, 95% CI: 1.00, 2.36) analyses. In metastatic DTCs, 4.9% of patients received chemotherapy in 2013, which was not significantly higher than in previous years (p = 0.755). CONCLUSIONS Overall, chemotherapy use among MTCs increased marginally following the FDA's approval of MKIs in 2011, although their use remains very low. MKIs were infrequently used in metastatic DTCs in 2013. Future studies examining patterns of chemotherapy in thyroid cancer patients are warranted.
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Affiliation(s)
- Stacey A. Fedewa
- Surveillance and Health Services Research, American Cancer Society, Emory University School of Medicine, Atlanta, Ga., USA
- *Stacey A. Fedewa, MPH, Surveillance and Health Services Research, American Cancer Society, 250 Williams Street, Atlanta, GA 30303 (USA), E-Mail
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Emory University School of Medicine, Atlanta, Ga., USA
| | - Amy Y. Chen
- Department of Otolaryngology, Emory University School of Medicine, Atlanta, Ga., USA
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Parikh RR, Yahalom J. Older patients with early-stage diffuse large B-cell lymphoma: the role of consolidation radiotherapy after chemoimmunotherapy. Leuk Lymphoma 2016; 58:614-622. [DOI: 10.1080/10428194.2016.1205739] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Rahul R. Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Chen Q, Ayer T, Nastoupil LJ, Koff JL, Staton AD, Chhatwal J, Flowers CR. Population-specific prognostic models are needed to stratify outcomes for African-Americans with diffuse large B-cell lymphoma. Leuk Lymphoma 2015; 57:842-51. [PMID: 26415108 DOI: 10.3109/10428194.2015.1083098] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Diffuse large B-cell lymphoma (DLBCL) demonstrates significant racial differences in age of onset, stage, and survival. To examine whether population-specific models improve prediction of outcomes for African-American (AA) patients with DLBCL, we utilized Surveillance, Epidemiology, and End Results data and compared stratification by the international prognostic index (IPI) in general and AA populations. We also constructed and compared prognostic models for general and AA populations using multivariable logistic regression (LR) and artificial neural network approaches. While the IPI adequately stratified outcomes for the general population, it failed to separate AA DLBCL patients into distinct risk groups. Our AA LR model identified age ≥ 55 (odds ratio 0.45, [95% CI: 0.36, 0.56], male sex (0.75, [0.60, 0.93]), and stage III/IV disease (0.43, [0.34, 0.54]) as adverse predictors of 5-year survival for AA patients. In addition, general-population prognostic models were poorly calibrated for AAs with DLBCL, indicating a need for validated AA-specific prognostic models.
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Affiliation(s)
- Qiushi Chen
- a H. Milton Stewart School of Industrial & Systems Engineering, Georgia Institute of Technology , Atlanta , GA , USA
| | - Turgay Ayer
- a H. Milton Stewart School of Industrial & Systems Engineering, Georgia Institute of Technology , Atlanta , GA , USA
| | - Loretta J Nastoupil
- b Department of Lymphoma/Myeloma, Division of Cancer Medicine , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Jean L Koff
- c Department of Hematology/Oncology , Winship Cancer Institute, Emory University , Atlanta , GA , USA
| | - Ashley D Staton
- c Department of Hematology/Oncology , Winship Cancer Institute, Emory University , Atlanta , GA , USA
| | - Jagpreet Chhatwal
- d Department of Health Services Research , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Christopher R Flowers
- c Department of Hematology/Oncology , Winship Cancer Institute, Emory University , Atlanta , GA , USA
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Vargo JA, Gill BS, Balasubramani GK, Beriwal S. Treatment Selection and Survival Outcomes in Early-Stage Diffuse Large B-Cell Lymphoma: Do We Still Need Consolidative Radiotherapy? J Clin Oncol 2015; 33:3710-7. [DOI: 10.1200/jco.2015.61.7654] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The choice between chemotherapy alone and chemotherapy plus consolidative radiotherapy (RT) for diffuse large B-cell lymphoma (DLBCL) remains controversial. We aimed to define factors affecting treatment selection and the resulting survival outcomes. Patients and Methods Using the National Cancer Data Base, we identified 59,255 patients with stages I and II DLBCL treated with multiagent chemotherapy alone or chemotherapy plus consolidative RT between 1998 and 2012. Univariable and multivariable analyses were performed to identify sociodemographic, treatment, and tumor characteristics predictive of overall survival (OS) and treatment use. Propensity-adjusted Cox proportional hazard ratios for survival were used to account for indication bias. Results Of the 59,255 patients with DLBCL enrolled onto the study, 46% had stage II disease, 42% had extranodal disease, and 58% were more than 60 years of age. Only 39% received combined-modality therapy, and this proportion significantly declined from 47% in 2000 to 32% in 2012 (P < .001). Treatment selection was significantly influenced by race, comorbidity, insurance type, education quartile, facility type, age, stage, B symptoms, distance from treatment facility, and year of diagnosis. The median follow-up time was 60 months (interquartile range, 33 to 93). Estimated 5-year and 10-year OS rates were, respectively, 79% and 59% for all patients, 75% and 55% for patients receiving chemotherapy alone, and 82% and 64% for patients receiving combined-modality therapy (P < .001). Even after adjusting for immortal times and indication bias, combined-modality therapy was associated with better OS (HR, 0.66; 95% CI, 0.61 to 0.71; P < .001) than was chemotherapy alone. Conclusion Use of consolidative RT after multiagent chemotherapy in DLBCL is decreasing in the modern era. Selection of treatment strategy is affected by both classical prognostic features and socioeconomic factors. Abandonment of combined-modality therapy in favor of chemotherapy alone negatively affects patient survival.
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Affiliation(s)
- John A. Vargo
- John A. Vargo, Beant S. Gill, and Sushil Beriwal, University of Pittsburgh Cancer Institute; and Goundappa K. Balasubramani, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Beant S. Gill
- John A. Vargo, Beant S. Gill, and Sushil Beriwal, University of Pittsburgh Cancer Institute; and Goundappa K. Balasubramani, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Goundappa K. Balasubramani
- John A. Vargo, Beant S. Gill, and Sushil Beriwal, University of Pittsburgh Cancer Institute; and Goundappa K. Balasubramani, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Sushil Beriwal
- John A. Vargo, Beant S. Gill, and Sushil Beriwal, University of Pittsburgh Cancer Institute; and Goundappa K. Balasubramani, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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Parikh RR, Grossbard ML, Harrison LB, Yahalom J. Impact of delays in definitive treatment on overall survival: a National Cancer Database study of patients with Hodgkin lymphoma. Leuk Lymphoma 2015; 57:1074-82. [PMID: 26374099 DOI: 10.3109/10428194.2015.1094696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The purpose of this large observational study was to examine outcomes in patients with Hodgkin lymphoma (HL) by timing to definitive chemotherapy (TTC) using standard and propensity score (PS)-adjusted Cox proportional hazards models. From 1998-2011, 56,457 patients with stage I-IV HL were studied, with a median follow-up of 6.0 years (median age=39). Median TTC was 26 days from diagnosis. The cohort of "early" (<60 days from diagnosis) TTC patients included 45,307 (80.3%) patients and "late" (≥60 days) TTC was 11,150 (19.7%). Patients were more likely to experience early TTC if they were of a younger age, at an advanced stage, with "B" symptoms, favorably insured, favorable socioeconomic status, and treated at comprehensive cancer center (all p<0.05). Ten-year overall survival for patients with early TTC was 73.2% vs. 70.0% for those with late TTC (HR=0.87; 95%CI, 0.83-0.92, p<0.0001). After PS-matching for co-variates, early TTC was not associated with overall survival (HR=0.96; 95%CI, 0.85-1.08, p=0.51). This represents the only study to evaluate overall survival by time to definitive treatment for HL.
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Affiliation(s)
- Rahul R Parikh
- a Mount Sinai Beth Israel Medical Center & Mount Sinai St. Luke's-Roosevelt Hospitals, Mount Sinai Health System , Department of Radiation Oncology , New York
| | - Michael L Grossbard
- b Laura and Isaac Perlmutter Cancer Center, New York University Langone Medical Center , Division of Hematology-Oncology , New York
| | - Louis B Harrison
- c Moffitt Cancer Center and Research Institute , Department of Radiation Oncology , Tampa , FL , and
| | - Joachim Yahalom
- d Memorial Sloan-Kettering Cancer Center , Department of Radiation Oncology , New York , NY , USA
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Racial Differences in the Overall Survival of Hairy Cell Leukemia in the United States: A Population-Based Analysis of the Surveillance, Epidemiology, and End Results Database. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:484-8. [DOI: 10.1016/j.clml.2015.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 03/18/2015] [Accepted: 03/18/2015] [Indexed: 01/16/2023]
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Gill BS, Vargo JA, Pai SS, Balasubramani GK, Beriwal S. Management Trends and Outcomes for Stage I to II Mantle Cell Lymphoma Using the National Cancer Data Base: Ascertaining the Ideal Treatment Paradigm. Int J Radiat Oncol Biol Phys 2015; 93:668-76. [PMID: 26461009 DOI: 10.1016/j.ijrobp.2015.07.2265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/24/2015] [Accepted: 07/13/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE Mantle cell lymphoma (MCL) is a rare, albeit aggressive subset of non-Hodgkin lymphoma, resulting in varied treatment approaches. Given the paucity of data defining the optimal management for early-stage MCL, we conducted an analysis using the National Cancer Data Base (NCDB) to identify practice patterns and outcomes. METHODS AND MATERIALS The NCDB was queried for patients with stage I to II MCL diagnosed from 1998 to 2012 receiving chemotherapy (CT) or radiation therapy (RT), or both (CT+RT). Univariate and multivariable analyses for factors associated with treatment selection were completed using logistic regression. Propensity scores with inverse probability treatment weighting (IPTW) were calculated based on the conditional probability of receiving CT+RT. The log-rank test and Cox proportional hazards modeling with IPTW adjustment were conducted for the survival analyses. RESULTS In total, 2539 patients were identified. The key characteristics were as follows: 69% were male, 71% were aged ≥60 years, 28% had extranodal involvement, and 51% had stage I disease. Of the 2539 patients, 70% underwent CT, 11% underwent RT, and 19% underwent CT+RT. The use of CT+RT decreased from 23.1% to 14.1% in 1998 to 2002 and 2010 to 2012 (P<.001). CT+RT usage was lower for patients with the following characteristics: age ≥60 years, female sex, stage II disease, and the presence of B symptoms. With a median follow-up period of 42.8 months, the unadjusted 3-year overall survival estimates for patients receiving CT, RT, or CT+RT were 67.8%, 72.4%, and 79.8%, respectively (P<.001). After correcting for indication bias through IPTW-adjusted modeling, CT+RT reduced the risk of overall mortality compared with monotherapy (hazard ratio 0.65, P=.029). CONCLUSIONS Although uncommon, patients with stage I-II MCL can have favorable outcomes. Despite a continued decline in the usage of consolidative RT, combined modality therapy improves survival in this cohort compared with monotherapy.
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Affiliation(s)
- Beant S Gill
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - John A Vargo
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Sarah S Pai
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Goundappa K Balasubramani
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
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Olszewski AJ, Shrestha R, Cook NM. Race-specific features and outcomes of nodular lymphocyte-predominant Hodgkin lymphoma: Analysis of the National Cancer Data Base. Cancer 2015; 121:3472-80. [PMID: 26149294 DOI: 10.1002/cncr.29527] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/02/2015] [Accepted: 03/20/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is higher among African Americans than among other races, but to the authors' knowledge, the characteristics of NLPHL in this population have not been evaluated. The authors compared clinical features, treatments, and survival of black and white patients with NLPHL using the National Cancer Data Base. METHODS The authors extracted the records of 602 black and 1950 white patients with NLPHL who were diagnosed between 1998 and 2011. Overall survival (OS) was compared using the log-rank test. RESULTS Black patients were on average younger than white patients (median age, 42 years vs 45 years; P =.0001), more often female (49% vs 29%; P<.0001), and more likely to have the axillary lymph nodes as the primary disease site (25% vs 17%; P =.0002). They also had unfavorable socioeconomic characteristics, a higher rate of no treatment in patients with early-stage disease, and a longer time to therapy initiation (median, 53.5 days vs 47 days; P<.0001). Despite this, the authors found no significant difference between the races with regard to stage distribution or survival (P =.39). OS at 7 years was 90.1% in patients with early-stage (American Joint Committee on Cancer stage IA/B, IIA) and 79.4% in patients with advanced stage (American Joint Committee on Cancer stage IIB, III/IV) NLPHL. Survival in the early stage of disease was not found to be significantly different after various treatment strategies (stratified log-rank P = .18), except that the administration of chemotherapy was associated with a better outcome in black patients (log-rank P =.011 vs P =.81 for white patients). CONCLUSIONS Differences in clinical presentation suggest the interaction of race-specific and sex-specific susceptibility factors for NLPHL. Further research is needed to elucidate these factors, and to investigate possible heterogeneous effects of treatments by race. Clinical trials comparing standard treatment strategies are unlikely to detect differences in OS among patients with early-stage NLPHL.
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Affiliation(s)
- Adam J Olszewski
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Department of Medicine, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island
| | - Rajesh Shrestha
- Department of Medicine, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island
| | - Nathaniel M Cook
- Division of Hematology-Oncology, Roger Williams Medical Center, Providence, Rhode Island
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Flowers CR, Nastoupil LJ. Identifying racial differences in nodular lymphocyte-predominant Hodgkin lymphoma. Cancer 2015; 121:3387-9. [PMID: 26149195 DOI: 10.1002/cncr.29526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 05/20/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Christopher R Flowers
- Department of Hematology and Oncology, Emory University School of Medicine, Winship Cancer Institute, Atlanta, Georgia
| | - Loretta J Nastoupil
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
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