Original StudyPersistent Disparities Among Patients With T-Cell Non-Hodgkin Lymphomas and B-Cell Diffuse Large Cell Lymphomas Over 40 Years: A SEER Database Review
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)
- et al.
Outcome of diffuse large B-cell lymphoma in the United States has improved over time but racial disparities remain: review of SEER data
Clin Lymphoma Myeloma Leuk
(2011) - et al.
Poorer prognosis of African-American patients with mycosis fungoides: an analysis of the SEER dataset, 1988 to 2008
Clin Lymphoma Myeloma Leuk
(2014) - et al.
CHOP is superior to CNOP in elderly patients with aggressive lymphoma while outcome is unaffected by filgrastim treatment: results of a Nordic Lymphoma Group randomized trial
Blood
(2003) - et al.
A SAS Macro for Estimation of Direct Adjusted Survival Curves Based on a Stratified Cox Regression Model
Computer Methods and Programs in Biomedicine
(2007) - et al.
The prognostic role of gender in survival of adult cancer patients. EUROCARE Working Group
Eur J Cancer
(1998) - et al.
Influence of morphology on survival for non-Hodgkin lymphoma in Europe and the United States
Eur J Cancer
(2008) - et al.
Cigarette smoking and alcohol consumption as determinants of survival in non-Hodgkin's lymphoma: a population-based study
Ann Oncol
(2006) Rituximab in combination with CHOP improves survival in elderly patients with aggressive non-Hodgkin's lymphoma
Semin Oncol
(2002)- et al.
Dose-dense rituximab-CHOP compared with standard rituximab-CHOP in elderly patients with diffuse large B-cell lymphoma (the LNH03-6B study): a randomised phase 3 trial
Lancet Oncol
(2013) - et al.
Origins of socio-economic inequalities in cancer survival: a review
Ann Oncol
(2006)
Relapsed and refractory aggressive NHL: time for a change
Transfus Apher Sci
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
Outcome disparities in multiple myeloma: a SEER-based comparative analysis of ethnic subgroups
Br J Haematol
The impact of race, age, and sex in follicular lymphoma: a comprehensive SEER analysis across consecutive treatment eras
Am J Hematol
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
Racial differences in the presentation and outcomes of diffuse large B-cell lymphoma in the United States
Cancer
Racial differences in treatment and survival in older patients with diffuse large B-cell lymphoma (DLBCL)
BMC Cancer
Rituximab use and survival after diffuse large B-cell or follicular lymphoma: a population-based study
Leuk Lymphoma
Survival in advanced diffuse large B-cell lymphoma in pre- and post-rituximab eras in the United States
Anticancer Res
The epidemic of non-Hodgkin lymphoma in the United States: disentangling the effect of HIV, 1992-2009
Cancer Epidemiol Biomarkers Prev
Ethnic variations in diagnosis, treatment, socioeconomic status, and survival in a large population-based cohort of elderly patients with non-Hodgkin lymphoma
Cancer
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