Clinical disparities in enteropathy-associated T-cell lymphoma: A national cancer database study of 736 patients treated at academic and community cancer centers Free

I) Background

Enteropathy-associated T-cell lymphoma (EATL) represents 3% of peripheral T-cell lymphomas. It constitutes two thirds of all primary intestinal T-cell lymphomas in Europe and the USA, with a strong association with celiac disease (ISBN: 9789283245209). It affects patients in the sixth decade of life, with a mild male predominance (PMID: 21566094).

Although prior studies have assessed population-level outcomes in EATL, national-level comparisons of clinical characteristics and survival by facility type are rare. This study represents the largest retrospective cohort analysis to date examining the impact of treatment facility—Academic Cancer Programs (ACPs) versus Community Cancer Programs (CCPs)—on patient demographics, treatment patterns, and survival outcomes in EATL.

II) Method

We conducted a retrospective analysis of EATL cases in the U.S. from 2004-2022, using the National Cancer Database (NCDB). Facilities were classified as ACPs (Academic/research programs, including NCI centers) and CCPs (Community, comprehensive community, and integrated network cancer programs). Demographic, clinical, and treatment variables were compared between cohorts. Overall survival (OS) was assessed using Kaplan–Meier and Cox proportional hazards models, adjusted for age, race/ethnicity, insurance status, Charlson–Deyo score, and distance from treating facility.

III) Results

A total of 736 patients with EATL were identified. Data on facility type were available for 705 patients (96%), including 420 (57%) treated at ACPs and 285 (39%) at CCPs. The remaining 31 patients (4%) lacked facility type data and were excluded from comparative analyses.

Both cohorts had a predominance of male patients (61% ACPs and 59% CCPs). Younger patients (< 60 years) were more often treated at ACPs (31% vs 25%; p < 0.001), whereas older patients (≥75 years) were more common at CCPs (34% vs 19%). Race/ethnicity distributions were similar between groups: White (78% ACPs and 79% CCPs), Black (11% ACPs and 10% CCPs), and Hispanic (9% ACPs and 6% CCPs).

Insurance coverage patterns varied by treatment setting. At ACPs, private insurance (40%) was the most common payor, followed by Medicare (47%). In contrast, Medicare was the leading payor at CCPs (58%), followed by private insurance (30%). Rates of Medicaid coverage and uninsured patients were low in both cohorts.

Socioeconomic factors such as income, education level, and residence location was comparable. However, patients treated at ACPs lived farther from their treatment centers compared to those at CCPs (12 miles vs. 8.6 miles; p < 0.001).

A significantly greater percentage of patients at ACPs received systemic treatment (74%) compared to those at CCPs (66%; p=0.009). Median time to treatment initiation was similar between both groups. When analyzed by treatment type, time to chemotherapy initiation remained similar, but time to immunotherapy initiation was lower at CCPs (29.5 vs 56 days; p=0.003).

Short-term outcomes revealed a higher 90-day mortality at ACPs compared to CCPs (43% vs 37%, respectively; p<0.003). However, the median follow-up time was longer at ACPs (7.4 vs 4.4 months; p<0.001). The percentage of patients alive at last follow-up was higher at ACPs (18% vs. 10%; p<0.001). Adjusted OS at 2, 5, and 10 years was marginally superior at ACPs vs CCPs (0.263 vs. 0.211, 0.178 vs. 0.157, and 0.133 vs. 0.085, respectively), resulting in a longer adjusted median survival time at ACPs (0.6 vs 0.4; p=0.0017).

IV) Conclusions

Although EATL affects a broad socioeconomic spectrum, its distribution by treatment facility differs. CCPs manage a larger proportion of elderly patients with greater reliance on Medicare. While residence location was similar between groups, patients at CCPs traveled shorter distances, suggesting disparities in economic resources and transportation access needed to reach academic centers, particularly among the older cohort treated at CCPs.

Short-term outcomes, measured by 90-day mortality favored CCPs. However, the proportion of patients alive at last follow-up and adjusted median survival were higher at ACPs. These superior outcomes could be explained by longer follow-up and greater use of systemic therapies, likely reflecting greater access to resources and more consistent adherence to clinical guidelines at academic centers. An older, potentially more vulnerable population at CCPs may also contribute to poorer long-term outcomes.