Nonbiological Factors Affecting Outcomes in Adolescent and Young Adults with Lymphoma

Background: Lymphoma is one of the most common cancers in adolescent and young adults (AYA). Although histology, stage, age, and gender are known to affect outcome, little is known about nonbiological factors (NBF) that may affect access to care on survival.

Objectives: To determine the impact of NBF in the survival of AYA with classical Hodgkin lymphoma (cHL) or non-Hodgkin lymphoma (NHL), including diffuse large B-cell lymphoma (DLBCL), Burkitt lymphoma (BL), lymphoblastic lymphoma (LL), and anaplastic large cell lymphoma (ALCL).

Design/Methods: The impact of NBF (insurance status, median household income, and educational achievement in the county of residence) along with biological factors (histology, stage, gender, age, and race/ethnicity) on survival of AYA lymphoma patients was analyzed using a SEER-18 (Surveillance, Epidemiology, and End Results) cohort diagnosed between 2007 and 2014.

Results: There were 8,173 cases of cHL and 4,973 cases of NHL with a median follow-up of 44 months and 32 months, respectively. Five-year overall survival (OS) for AYA patients with localized cHL according to insurance status was 98% vs. 91% vs. 92% for insured, Medicaid, and uninsured patients, respectively (P < 0.001). The 5-year OS for advanced stage cHL was 91.5% vs. 85% vs. 85% for insured, Medicaid, and uninsured patients, respectively (P < 0.001). In multivariate analysis, the increase risk of death was associated with Medicaid (HR 2.23, 95% C.I. 1.76-2.81), and uninsured (HR 1.88, 95% C.I. 1.38-2.55), after adjustment for age, gender, histology and stage (P<0.001). Five-year OS for AYA patients with localized NHL according to insurance status was 90% vs. 76.5% vs. 84.5% for insured, Medicaid, and uninsured patients, respectively (P < 0.001). The 5-year OS for advanced stage NHL was 76% vs. 57%, and 62% for insured, Medicaid, and uninsured patients, respectively (P < 0.001). In multivariate analysis, the increased risk of death in AYA NHL was associated with Medicaid (HR 1.95, 95% CI 1.67-2.27), and uninsured (HR 1.48, 95% CI 1.18-1.84) (P<0.001) and county level of income in the second (HR 1.33, 95% C.I. 1.07-2.64), third (HR 1.54, 95% C.I. 1.25-1.90), and forth (HR 1.57, 95% C.I. 1.27-1.93) (P< 0.001) lower quartiles (P<0.001), after adjustment for age, gender, histology, and stage.

Conclusion: Lack of insurance or Medicaid insured status and lower income are associated with increased mortality in AYA lymphomas, indicating an opportunity to increase outcomes by addressing NBF.