Although Hodgkin lymphoma (HL) is frequently treated with a combination of chemotherapy and radiation therapy, there is a movement towards omitting radiation therapy altogether. According to a recent analysis of National Cancer Data Base information, the decision to eliminate radiation therapy in non-HL may be associated with socioeconomic factors.
It may also negatively impact survival outcomes, according to researchers led by Adam J. Olszewski, MD, assistant professor at Alpert Medical School of Brown University and an ASH Scholar Award recipient for 2015. To define factors affecting treatment selection and resulting survival outcomes, Dr. Olszewski and colleagues identified 20,600 HL patients treated with combined-modality approach (CMT) or chemotherapy alone between 2003 and 2011.
More than half of the population were women (51.3%), and the majority (58.8%) were younger than 40 years at diagnosis.
Although clinical guidelines from the early 2000s recommend CMT in HL patients, the researchers noted, physicians appear to be concerned about the use of radiation therapy and are choosing to minimize treatment where possible. On average, 49.5 percent of patients received CMT, but the proportion steadily declined from 2003 to 2011 – from 59.4 to 45.2 percent. The decrease in the use of CMT was most pronounced in younger patients – particularly women younger than 30 years at the time of diagnosis. It was not significant in women over the age of 50, or men over the age of 70.
“It appears that oncologists and patients are uncomfortable with current standards of care, which cure a majority of patients, but carry toxicity that is perceived as excessive,” Dr. Olszewski told ASH Clinical News.
Aside from classical prognostic factors (age, stage, tumor location, histology, and comorbidities), the researchers found that treatment selection was significantly influenced by gender, race, location, and type of insurance.
- African-American patients were 16 percent less likely to receive CMT (OR=0.84; 95% CI 0.75–95)
- Patients who lived more than 50 miles away from a treatment facility were less likely to receive CMT (OR=0.75; 95% CI 0.66–86)
- Uninsured patients had the lowest odds of receiving CMT (OR=0.72; 95% CI 0.64–82)
- Academic and research facilities were less likely to use CMT than community centers (OR=0.81; 95% CI 0.69–96)
“Our study identified particularly vulnerable groups (older patients, African Americans, patients who are uninsured or with Medicaid) with lower rates of combined modality therapy,” Dr. Olszewski said. “Oncologists should recognize potential barriers to effective treatment, support those patients in the best decision-making, and mobilize resources to assist them during the treatment.”
Five-year overall survival (OS) and relative survival (RS) in the entire cohort were 89.6 percent and 94.3 percent, respectively.
CMT was also associated with better OS (hazard ratio [HR] = 0.61; 95% CI 0.53–0.70) and RS (excess HR=0.42; 95% CI 0.33–0.54), after adjustment for guarantee-time and indication biases.
“In my opinion, the best way to change the standard of care is to bring to the forefront novel approaches that revolutionized treatment of relapsed/refractory HL,” he noted, such as brentuximab vedotin and the PD-1 inhibitors that could be integrated into CMT.
The extent to which socioeconomic factors affected treatment decisions was both “very surprising” and “very disturbing,” he added, “particularly because most patients with early-stage HL are young and may be disadvantaged by the way we have been rationing health care in the United States.”
Olszewski AJ, Shrestha R, Castillo JJ. Treatment selection and outcomes in early-stage classical Hodgkin lymphoma: analysis of the National Cancer Data Base. J Clin Oncol. 2015 January 12. [Epub ahead of print]