Lechowicz, the Margaret Rollin Chair of Oncology, Hematology, and Medical Oncology at Emory University Winship Cancer Institute, presented an analysis of public data on Surveillance, Epidemiology, and End Outcomes (SEER) from 1973 to 2011, among other data, looking at the current state of differences in both adults and children in this patient population at the 2021 Society of Hematology Oncology (SOHO) Annual Conference.
By looking at this data, Lechowicz and her fellow researchers were able to identify current trends and areas of socioeconomic inequalities that need to be addressed by the broader healthcare landscape. One of the key differences between both adults and children with T-cell lymphoma was that ethnic and racial minorities had worse median overall survival (OS) compared to other patients.
“African American patients have the worst median overall survival compared to white or white patients,” she explained in the presentation. “Why we keep doing what we do is the fact that, unfortunately, [researchers] found no significant improvement in survival in patients with T-cell lymphoma.
Looking at this set of data, the researchers found that in T-cell lymphomas, women had a better median OS of 3.3 years compared to men at 2.3 years (P < .001), but younger patients (18-44 years old ) a higher median OS of 9.4 years (HR 0.35; 95% CI 0.31-0.38) compared to elderly patients (75 years or older) with a median OS of 1 year (P < 0.001). However, when researchers performed a multivariate analysis of black patients, they had the worst median OS compared with white patients, 1.7 years vs 3.1 years, respectively (HR 1.29; 95% CI 1.18-1.42; P <0.001). In addition, the median OS in white patients versus Hispanic patients was 5.8 years versus 2.8 years, highlighting the large differences between white patients and ethnic minorities.
“Knowing that ethnic and racial minorities had worse median overall survival for both T and B cell lymphomas, [the conclusion is] that (researchers) thought we needed not only more biological studies, but also better use of triage for health care resources and more participants (in clinical trials), particularly in underrepresented minority patients,” Lechowicz said.
Lechowicz also noted that these differences persisted in African-American children compared to white children with T-cell lymphomas. The SEER registry looked at 10,201 children, from infants to 19-year-olds, diagnosed and treated with T-cell lymphomas from 2000-2017.2
Survival results from this analysis suggested that children with T-cell lymphoma were approximately 3 times more likely to die (HR 2.79; 95% CI, 0.39-19.9) than white children, and that children with undifferentiated tumors were 5 times more likely to die. were more likely to die (HR 5.63; 95% CI 0.73-43.3) than those with differentiated tumors. Lechowicz also emphasized that there were even more differences between children who were affected by other social determinants of health, such as where they lived, rural versus urban and household income.
“When people [discuss] inequalities, [they] often talk about the fact that it’s not just race-based,” Lechowicz noted. “We want people to have a better understanding when they think about this type of work and addressing social determinants of health to advance cancer health in the United States.”
Children in rural areas were 29% more likely to die than children in metropolitan areas (HR = 1.29, 95% CI, 1.07–1.56), in addition, children in the first quintile of income (less than $35,000-$39,99) more likely to die from T-cell lymphoma than those children in a 5th quintile household ($70,000-$75,000). In addition, children in the higher quintile were 21% less likely to die than those in the first (HR 0.79; 95% CI 0.57-1.09).
Social determinants of health continued to have an effect, with patterns of racial disparity in SEER data from patients over 15 years of age with peripheral T-cell lymphoma diagnosed between 2000 and 2012.3 Among all types of peripheral T-cell lymphoma, non-Hispanic whites still had the highest OS probability (P < .001), but in patients with adult t-cell leukemia/lymphoma the OS probability was lowest in black patients (P < .001).
Current solutions to close the inequality gap include expanding Medicaid coverage to patients and looking at the broader inequalities associated with the racial inequalities seen in this analysis. When it comes to cancer in general, studies have shown the benefits of patients being able to quickly enroll in Medicaid before starting their treatment. What was more beneficial for patients was that they were enrolled on Medicaid prior to diagnosis.
According to an analysis of SEER data, most patients enrolled were more likely to be ethnic minorities after diagnosis and late-stage diagnosis was common in this group.5 Mortality was highest among those enrolled after their diagnosis, providing researchers with further evidence that Medicaid and insurance prior to this diagnosis offer a significant benefit in preventing late-stage illness and death. Lechowicz also highlighted ongoing studies to evaluate more recent data and to discuss the limitations of health professionals addressing a problem that requires structural and economic changes in the lives of many patients.
“In our prostate, as well as in our breast cancer groups, [one solution they have found is] reaching out to communities with people who look like the patients themselves,” noted Lechowicz when discussing solutions cancer centers can undertake to educate patients and enroll in trials. “It doesn’t matter what that denomination is, I know it locally. We got into the breast cancer groups where church elders from historically black churches come and talk about different things related to cancer.”
1. Lechowicz, M. Differences in treatment in patients with T-cell lymphoma. Presented at: 62nd American Society of Hematology Annual Meeting and Exposition, December 5-8, 2020. Executive Summary 700. Accessed September 8, 2021.
2. MokdadAH, Dwyer-Lindgren L, Fitzmaurice C, et al. Trends and patterns of differences in cancer mortality in US counties, 1980-2014. JAMA. 2017;317(4):388-406. doi: 10.1001/jama.2016.20324
3. Crozier JA, Sher T, Yang D, et al. Persistent differences between patients with T-cell non-Hodgkin lymphomas and B-cell diffuse large cell lymphomas over 40 years: a SEER Database Review. Clin Lymphoma Myeloma Fun. 2015;15(10):578-85. doi: 10.116/j.clml.2015.06.005
4. Holmes L Jr, Williams MA, Halloran DR, et al. Social gradient predicts survival lag of African American/Black children with lymphoma. J Natl Med Assoc. 2021 Aug;113(4):414-427. doi: 10.116/j.jnma.2021.02.006
5. Adams SV, Newcomb PA, ShustovAR. Racial patterns of peripheral T-cell lymphoma incidence and survival in the United States. J Clin Oncol. 2016 March 20;34(9):963-71. doi: 10.1200/JCO.2015.63.5540
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