Original Study
Persistent Disparities Among Patients With T-Cell Non-Hodgkin Lymphomas and B-Cell Diffuse Large Cell Lymphomas Over 40 Years: A SEER Database Review

https://doi.org/10.1016/j.clml.2015.06.005Get rights and content

Abstract

Background

As of 2013, more than 550,000 people are living with non-Hodgkin lymphoma (NHL).

Patients and Methods

We undertook a large Surveillance Epidemiology and End Results (SEER) based analysis to describe outcome disparities in different subgroups of aggressive T-cell and B-cell NHL patients, with a focus on various ethnicities.

Results

The final analysis included 7662 patients with T-cell and 84,910 with B-cell NHL. Survival analysis revealed that male sex and increasing age were independent predictors of worse overall survival (OS; P < .001). For aggressive T-cell NHL, there was no significant improvement in median OS between 1973 and 2011 (P = .081), and ethnic minorities (Asians, Hispanics, and African Americans) had significantly worse OS than whites (P < .001). There were similar trends for age, sex, and race for diffuse large B-cell NHL, but a significant improvement in median OS was seen over time (P < .001).

Conclusion

These results are the first to elicit outcomes in a broad classification of ethnic minorities and underscore the urgency for development of novel therapeutics, especially in T-cell NHL. In addition, in-depth studies of disease biology and health care utilization are required for better triage of health care resources, especially for ethnic minorities.

Introduction

Non-Hodgkin lymphoma (NHL) encompasses a diverse group of malignant neoplasms derived from B cells, T cells, or natural killer cells. It is estimated that more than 558,000 individuals in the United States are living with NHL in 2013 and the incidence of NHL is increasing among men.1, 2 Age, sex, and race/ethnicity have been shown to affect overall survival (OS) among patients with multiple myeloma and different lymphoid malignancies, including chronic lymphocytic leukemia and follicular B-cell NHL.3, 4, 5 Previous studies utilizing the Surveillance, Epidemiology, and End Results (SEER) database have focused on a specific NHL, such as diffuse large B-cell lymphoma.6, 7, 8 The few published studies evaluating outcome disparities in aggressive NHL are of limited relevance to current patients in view of significant changes in the standard treatments of these disorders over the last few decades.9, 10, 11, 12, 13 None of the studies has evaluated disparities in outcomes of patients with T-cell NHL.

In the 1980s, combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP regimen) was the standard treatment for NHL.14, 15 The addition of rituximab to CHOP in 1997 led to an improvement in OS in patients with B-cell NHL.16 New effective therapies for T-cell NHL are currently available, including romidepsin and pralatrexate. The impact of these new agents on patient outcomes, particularly among different population subgroups, remains to be fully characterized.17 We undertook a Surveillance Epidemiology and End Results (SEER)-based analysis to describe outcome disparities among different subgroups of aggressive T-cell and B-cell diffuse large cell lymphoma (DLCL) patients, with a focus on different racial/ethnic subgroups.

Section snippets

Data Source

The SEER public database 1973 to 2011 (SEER 18), based on the November 2011 submission, was used for the analysis (http://www.seer.cancer.gov).

Study Population

All cases of primary T-cell NHL and B-cell DLCL reported to the SEER cancer registry were evaluated. The following cases were excluded: if diagnosis of NHL was made at death certificate or autopsy, if patient's age was less than 18, if there were no follow-up records, or if there was no documentation of age at diagnosis, sex, or race/ethnicity.

Variable Definitions

The

Results

The final analysis included 7662 patients with T-cell NHL (58.9% male) and 84,910 patients with B-cell DLCL (53.7% male) as per the inclusion criteria described above. Patient characteristics are shown in Table 1. The percentage of patients with T-cell NHL and B-cell DLCL who were 65 or older was 44.5% and 54.2%, respectively. Racial/ethnic minorities (African American, Hispanic, Asian, and Native American) comprised 31.3% and 22.9% in T-cell and B-cell DLCL patients, respectively. Within the

Discussion

To our knowledge, this is the largest and most comprehensive evaluation of outcomes in patients belonging to different racial subgroups, including minorities, with T-cell NHL and B-cell DLCL in the United States.

In our analysis, we found that women had a statistically significant better median OS compared to men in T-cell NHL (3.3 years vs. 2.3 years, P < .001) and B-cell DLCL (6.4 years vs. 4.2 years, P < .001). This improved survival by multivariate analysis was independent of race/ethnicity,

Conclusion

Despite these limitations, our study shows that significant disparities in outcomes exist among racial/ethnic minorities with B-cell DLCL and T-cell lymphomas. These disparities have persisted despite the development of highly effective treatment for B-cell DLCL (rituximab) over the last 20 years. Future studies, especially conducted prospectively, are required to determine the exact causes of these disparities and to formulate strategies to ameliorate them.

Disclosure

The authors have stated that they have no conflicts of interest.

References (45)

  • S. Gangatharan et al.

    Relapsed and refractory aggressive NHL: time for a change

    Transfus Apher Sci

    (2013)
  • B.K. Edwards et al.

    Annual report to the nation on the status of cancer, 1975-2010, featuring prevalence of comorbidity and impact on survival among persons with lung, colorectal, breast, or prostate cancer

    Cancer

    (2014)
  • Blood Cancer Facts, 2013. Available at:...
  • S. Ailawadhi et al.

    Outcome disparities in multiple myeloma: a SEER-based comparative analysis of ethnic subgroups

    Br J Haematol

    (2012)
  • C. Nabhan et al.

    The impact of race, age, and sex in follicular lymphoma: a comprehensive SEER analysis across consecutive treatment eras

    Am J Hematol

    (2014)
  • C. Nabhan et al.

    The impact of race, ethnicity, age and sex on clinical outcome in chronic lymphocytic leukemia: a comprehensive Surveillance, Epidemiology, and End Results analysis in the modern era

    Leuk Lymphoma

    (2014)
  • P.J. Shenoy et al.

    Racial differences in the presentation and outcomes of diffuse large B-cell lymphoma in the United States

    Cancer

    (2011)
  • R. Griffiths et al.

    Racial differences in treatment and survival in older patients with diffuse large B-cell lymphoma (DLBCL)

    BMC Cancer

    (2010)
  • T.H. Keegan et al.

    Rituximab use and survival after diffuse large B-cell or follicular lymphoma: a population-based study

    Leuk Lymphoma

    (2013)
  • B.K. Shah et al.

    Survival in advanced diffuse large B-cell lymphoma in pre- and post-rituximab eras in the United States

    Anticancer Res

    (2014)
  • M.S. Shiels et al.

    The epidemic of non-Hodgkin lymphoma in the United States: disentangling the effect of HIV, 1992-2009

    Cancer Epidemiol Biomarkers Prev

    (2013)
  • M. Wang et al.

    Ethnic variations in diagnosis, treatment, socioeconomic status, and survival in a large population-based cohort of elderly patients with non-Hodgkin lymphoma

    Cancer

    (2008)
  • Cited by (24)

    • Survival Disparities of Diffuse Large B-Cell Lymphoma in a Community-Based Inner-City Cancer Center

      2021, Clinical Lymphoma, Myeloma and Leukemia
      Citation Excerpt :

      Diffuse large B-cell lymphoma (DLBCL) is the most common type of NHL and comprises approximately 30% of the NHL.3 Multiple studies have demonstrated race-based disparities in survival among patients with DLBCL across all stages, in the era both before and after rituximab.4-9 In an attempt to stratify heterogeneous populations into more uniform risk groups according to the presence or absence of certain clinical or laboratory variables, various prognostic markers are currently being utilized.10

    • Treatment approaches for older and oldest patients with diffuse large B-cell lymphoma – Use of non-R-CHOP alternative therapies and impact of comorbidities on treatment choices and outcome: A Humedica database retrospective cohort analysis, 2007–2015

      2020, Journal of Geriatric Oncology
      Citation Excerpt :

      Two-year PFS was prolonged in our female, compared to male, patients, similar to prior reports [32,33]. The impact of age on DLBCL treatment patterns and outcomes is well-recognized [34]. Although the International Prognostic Index (IPI) utilized an age cutoff of 60 years in the pre-rituximab era, more recent findings have suggested that age 70 years may be of greater prognostic value based upon post-rituximab era data [35,36].

    • Racial disparities, cancer and response to oxidative stress

      2019, Advances in Cancer Research
      Citation Excerpt :

      Effective strategies to identify causality and reduce disparities are warranted. NHL encompasses a diverse group of malignant neoplasms derived from B cells, T cells, or natural killer cells (Crozier et al., 2015). Similar to other malignancies, racial differences exist among NHL patients.

    View all citing articles on Scopus
    View full text