Addressing Racial Disparities in T-Cell Lymphoma Requires Look at Social Inequity

Mary Jo Lechowicz, MD

Treatment for patients with T-cell non-Hodgkin lymphomas has expanded, but as availability of treatment options have increased disparities for which patients have access to these treatments continues to persist. These disparities not only are widening among racial groups, but socioeconomic inequities should also be considered and addressed by the wider healthcare community, according to Mary Jo Lechowicz, MD.¹

Lechowicz, the Margaret Rollin Chair of oncology, hematology, and medical oncology at Emory University Winship Cancer Institute, presented an analysis of Surveillance, Epidemiology, and End Results (SEER) public data from 1973 to 2011, among other data, that looked at the current state of disparities in both adults and children in this patient population at the Society of Hematology Oncology (SOHO) 2021 Annual Conference.

By looking at these data Lechowicz and her fellow researchers were able to identify current trends and areas of socioeconomic inequities that need to be addressed by the broader healthcare landscape. One of the main disparities among both adults and children with T-cell lymphoma was that ethnic and racial minorities had a worse median overall survival (OS) compared withwith other patients.

“African American patients have the worst median overall survival compared withwith Caucasian or White patients,” she explained in the presentation. “Why we keep doing what we’re doing is the fact that, unfortunately, [researchers] did not find…significant improvement in survival in T cell lymphoma patients.”

Looking at this range of data, the researchers found that in T-cell lymphomas women had a better median OS of 3.3 years compared with men at 2.3 years (P < .001) but that younger patients (18-44 years old) had a higher median OS of 9.4 years (HR, 0.35; 95% CI, 0.31-0.38) compared with older patients (75 years old or greater) who had a median OS of 1 year (P < .001). However, when researchers conducted 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 < .001). Moreover, median OS in White patients vs Hispanic patients was 5.8 years vs2.8 years, highlighting the deep disparities 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 biologic studies, but better utilization of triage for healthcare resources and more participants (in clinical trials), particularly in underrepresented minority patients,” said Lechowicz.

Lechowicz also observed that these disparities persisted among African American children compared with White children with T-cell lymphomas. The SEER registry looked at 10,201 children, from infants to 19-year-olds, with T-cell lymphomas diagnosed and treated 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 those with undifferentiated tumors were 5 times more likely to die (HR 5.63; 95% CI, 0.73–43.3) than those with differentiated tumors. Lechowicz also highlighted that there were further disparities among children affected by other social determinants of health such as where they lived, rural vs urban, and household income.

“When people [discuss] disparities, [they] often talk about the fact that it is not based on race alone,” Lechowicz noted. “We want people to have a better understanding when they’re thinking about this kind of work and addressing social determinants of health in order to be able to advance cancer health equity in the United States.”

Children in rural areas were 29% more likely to die compared with children in metropolitan areas (HR = 1.29, 95% CI, 1.07–1.56), moreover, children in the first quintile of income (less than $35,000-$39,999) were more likely to die from T-cell lymphoma than those children in a household in the 5th quintile ($70,000-$75,000). Furthermore, children in the higher quintile were 21% less likely to die compared with those in the first (HR 0.79; 95% CI, 0.57–1.09).

Social determinants of health continued to have an effect, with racial disparity patterns emerging in SEER data of patients over 15-years-old with peripheral T-cell lymphoma diagnosed between 2000 and 2012.³ In 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 OS probability was lowest in Black patients (P < .001).

Current solutions to closing the disparity gap include expanding Medicaid coverage for patients and looking at the wider inequities that are tied to the racial disparities seen in these analysis. In cancer overall, studies have shown the benefit of patients who were able to quickly enroll on Medicaid before embarking on their treatment. What was more beneficial for patients was that they were enrolled on Medicaid before the diagnosis.

According to an analysis of SEER data most of the patients who enrolled after diagnosis were more likely to be an ethnic minority and late-stage diagnosis was common among this group.⁵ Mortality was highest in those who enrolled after their diagnosis, giving researchers further evidence that Medicaid and insurance prior to these diagnosis offers significant benefit to avoiding late-stage disease and mortality. Lechowicz also highlighted ongoing studies to evaluate more recent data and to discuss the limitations of healthcare workers addressing a problem that requires structural and economic changes in many patients’ lives.

“In our prostate, as well as our breast cancer groups, [one solution they have found is] going out to communities with people that look like the patients themselves,” Lechowicz noted when addressing solutions that cancer centers can undertake to educate and enroll patients on trials. “No matter what that denomination is, I know it locally, we’ve gotten to the breast cancer groups having church elders of historically black churches come and talk about different things with regard to cancer.”

_References

_{1. Lechowicz, M. Disparities in Treatment in Patients with T-Cell Lymphoma. Presented at: 62nd American Society of Hematology Annual Meeting and Exposition, December 5-8, 2020. Abstract 700. Accessed September 8, 2021.}

_{2. MokdadAH, Dwyer-Lindgren L, Fitzmaurice C, et al. Trends and Patterns of Disparities in Cancer Mortality Among 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 Disparities Among Patients With T-Cell Non-Hodgkin Lymphomas and B-Cell Diffuse Large Cell Lymphomas Over 40 Years: A SEER Database Review. Clin Lymphoma Myeloma Leuk. 2015;15(10):578-85. doi: 10.1016/j.clml.2015.06.005}

_{4. Holmes L Jr, Williams MA, Halloran DR, et al. Social gradient predicts survival disadvantage of African Americans/Black children with lymphoma. J Natl Med Assoc. 2021 Aug;113(4):414-427. doi: 10.1016/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 Mar 20;34(9):963-71. doi: 10.1200/JCO.2015.63.5540}