Background

Marginal zone lymphoma (MZL) is an indolent subtype of B-cell non-Hodgkin lymphoma, accounting for approximately 7% of cases (PMID 36485086). Among its three classic subtypes, extranodal MZL or mucosa-associated lymphoid tissue (MALT) represents 60–70% of diagnoses (PMID: 33829216). Adverse prognostic factors include advanced age, poor performance status, bone marrow involvement, and later stage at diagnosis (PMID 40260947). While observation is appropriate for indolent cases, chemoimmunotherapy remains the standard of care for patients requiring systemic treatment. (PMID 37605344) The selection between single-agent and combination regimens is often guided by clinical factors and has important implications for disease control and overall survival (OS).

To our knowledge, this is the first retrospective analysis using the National Cancer Database (NCDB) to compare sociodemographic characteristics, disease presentation, and survival outcomes in patients with MALT lymphoma treated at academic cancer programs (ACPs) versus community cancer programs (CCPs).

Methods

We conducted a retrospective analysis of patients diagnosed with MALT lymphoma in the United States between 2004-2022 using the NCDB. Patients were categorized by facility type: ACPs included academic and research programs (including NCI-designated centers), while CCPs included community, comprehensive community, and integrated network cancer programs. Demographic, clinical, and treatment characteristics were compared across cohorts. Kaplan-Meier and Cox proportional hazards models were used to evaluate OS adjusting for age, race/ethnicity, insurance, Charlson-Deyo comorbidity score, and distance from treating facility.

Results

Of 77,631 patients with MALT, 56% were treated at ACPs and 40% at CCPs. A greater proportion of patients were females for both ACPs and CCPs, 56% and 55%, respectively. The median age at diagnosis was 67 years for ACPs, and 70 years for CCPs, p<0.001; with most common age range being 60-75years, 43% for ACPs and 42% for CCPs, p<0.001.

The most frequent ethnicity in both groups was Non-Hispanic ,89.3% in ACPs vs 91.5% in CCPs, with a predominance of White race, followed by Black race. Black patients were more commonly treated at ACPs than CCPs (10% vs 7%, p<0.001).

Medicare was the most common payer among ACPs (53%), as well as for CCPs (60%); followed by private insurance, 36% vs 32%, respectively. For both groups, 2% of the patients were uninsured, p<0.001. Based on using 2016–2020 census median income quartiles, the most represented income bracket was ≥$74,063, 39% ACPs vs 34% CCPs. About 12% of patients in both cohorts resided in the lowest income quartile of <$46,277.

Clinical characteristics at diagnosis revealed that 7% of patients at ACPs had a Charlson-Deyo comorbidity score ≥2, compared to 9% at CCPs, p<0.001. The most frequent stage at diagnosis among ACPs and CCPs was Stage I, 41% vs 42%, respectively. Stage IV distribution among ACPs and CCPs was well balanced, 25% for both cohorts. The median time from diagnosis to initiation of treatment was 34 days for ACPs and 32 days for CCPs. Treatment initiation was similar, 56% for ACPs and 55% for CCPs, p<0.001.

Geographic access to care, measured as median distance from residence to reporting facility, was 10 miles for ACPs and 8 miles for CCPs.

On survival analysis, the 2, 5, and 10-year survival probabilities for ACPs vs CCPs were 89% vs 88%, 77% vs 75%, and 58% vs 56%, respectively. Median survival time was 12.7 years for ACPs and 11.7 years for CCPs, with a statistically significant OS advantage for ACPs p<0.001.

Conclusion

In this large national analysis of patients with MALT lymphoma using the NCDB, treatment at ACPs was associated with significantly improved OS compared to CCPs. This survival advantage persisted despite similar disease stage at presentation, insurance coverage, income distribution, and time from diagnosis to treatment initiation. Patients treated at ACPs were more likely to be younger and have fewer comorbidities, yet the magnitude of survival benefit suggests that institutional factors, such as access to multidisciplinary teams, broader therapeutic expertise, and enhanced supportive infrastructure, play an important role in optimizing outcomes. These findings reinforce the value of academic care models in managing indolent lymphomas and highlight the need for strategies that ensure equitable access to high-quality cancer care across all healthcare settings.

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2025
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