Victoria A. Vardell

Survival remains poor for T-cell prolymphocytic leukemia, though treatment in recent years, associated with access to novel therapies, and management at academic medical centers is associated with improved outcomes. There remains a critical need to improve the available treatment options for this population, and access to specialized academic medical centers, comprehensive supportive care, clinical trials, and early palliative care remains essential for T-PLL patients.

BACKGROUND: Kaposi sarcoma (KS) is a cutaneous and mucous membrane tumor caused by human/Kaposi sarcoma herpesvirus 8 (HHV-8), typically seen in immunocompromised patients, including those with HIV/AIDS. Patients from traditionally underserved and underrepresented (URM) populations have disparate survival outcomes across malignancies, however the effects of socioeconomic and demographic factors on survival have not been described on a large scale in KS. METHODS: KS patients diagnosed from 2004-2017 were identified in the National Cancer Database (NCDB). Overall survival (OS) was analyzed using Kaplan Meier and adjusted Cox regression methods, and repeated in a propensity score matched cohort, where White patients were matched to Black patients 1:1 for demographic factors and comorbidities. RESULTS: For the 4,034 identified patients, advanced age, Black race, HIV-positive status, and Charlson-Deyo score ≥1 were independently associated with decreased OS. Survival benefit was seen with Spanish/Hispanic ethnicity, private insurance, residence in areas of high educational attainment, and treatment at academic centers. Black patients had median survival of 99 months (95% confidence interval [CI] 73-124 months) compared to White patients (140 months, 95% CI 122-158 months) (p<0.001). Following propensity score matching, Black patients continued to have poorer OS compared to White patients (119 months versus 136 months, p=0.045). CONCLUSION: We describe the impact of socioeconomic factors and race on survival in KS, finding significantly reduced survival in Black patients, which persisted after controlling for covariates. These results highlight the need for directed efforts promoting equitable outcomes for underrepresented minorities.

Overall survival for chronic lymphocytic leukemia (CLL) patients by race; propensity score matched by age, Charlson-Deyo comorbidity score, insurance, and income and education level of zip code of residence.

Chronic lymphocytic leukemia (CLL) is the most prevalent adult leukemia, with the highest incidence in the White, non-Hispanic population. To better understand underrepresented minority CLL patients, patients diagnosed with CLL from 2004-2018 were identified in the National Cancer Database. Of 97 804 CLL patients, 90.7% of patients were White, 7.6% Black. Compared to White patients, Black patients were younger (median age 66 years vs. 70 years), more likely to have ≥1 comorbidity (27.9% vs. 21.3%), more likely to receive CLL-directed therapy at diagnosis (35.9% vs 23.6%; p<0.001), and had a shorter median OS of 7.0 years (95% CI 6.7-7.3) compared to White patients (9.1 years [95% CI 9.0-9.3]), p<0.001). On multivariate analysis, Black race was independently associated with shorter OS (HR 1.51 [95% CI 1.46-1.57], p<0.001), which was also demonstrated in a propensity score matched sample (matched by age, comorbidity, and socioeconomic features), where Black patients had shorter OS compared to White patients (HR 1.30 [95% CI 1.23-1.37, p<0.001]). In the largest study to date describing minority CLL patients, we found significantly reduced survival in Black CLL patients, highlighting the need for targeted efforts to provide equitable outcomes.

Treatment at academic cancer centers (ACs) is associated with improved survival across hematologic malignancies, though the benefit in multiple myeloma (MM) has not been examined. This study aims to evaluate survival outcomes at Commission on Cancer accredited ACs compared to non‐academic centers (NACs) for patients receiving MM‐directed therapy. The National Cancer Database (NCDB) was used to identify demographics and overall survival (OS) of MM patients diagnosed from 2004 to 2017 and to compare outcomes by facility type. Survival analysis was repeated in a propensity score matched cohort, with NACs matched 1:1 to ACs by age, race, comorbidity score, insurance, year of diagnosis, distance traveled, and income. Of 163 375 MM patients, 44.5% were treated at ACs. Patients at ACs were more likely to receive MM‐directed therapy compared to NACs (81% vs. 73%, p < .001). For patients receiving treatment, median OS at ACs was 71.3 months versus 41.2 months at NACs (p < .001). When adjusted for baseline demographics, patients treated at ACs had reduced mortality; hazard ratio (HR) 0.79 (95% CI 0.78–0.81, p < .001). The propensity score matched cohort maintained this survival benefit with a median OS of 59.9 months at ACs versus 37.0 months at NACs (p < .001), HR of 0.66 (95% CI 0.64–0.67, p < .001). ACs treated younger patients with fewer comorbidities and were more likely to treat racial minorities and patients with Medicaid or private insurance, and the uninsured. In this analysis, MM patients treated at ACs have significantly improved survival. While potentially related to access to specialized care, socioeconomic factors that drive facility selection may also contribute.

Background Treatment at academic cancer centers (ACs) has been associated with improved outcomes across hematologic malignancies, including acute myeloid leukemia and non-Hodgkin lymphoma. ACs offer the benefit of high treatment volume in addition to enrollment in clinical trials, involvement in post-graduate education, and expanded access to diagnostic and treatment related services. Though studies on multiple myeloma (MM) have demonstrated a survival benefit with treatment at both high-volume centers and at NCCN designated cancer centers, this is the largest study to date examining the benefit of academic centers. Methods The National Cancer Database was utilized to obtain data on patients diagnosed with MM between 2004-2017 for which data on treatment facility type was available. Using the Commission on Cancer facility categories, patients treated at ACs were compared to those treated at non-academic centers (NACs), including small and large volume community cancer centers. Demographic and treatment characteristics were compared between centers, with median overall survival (OS) assessed by Kaplan Meier. Cox regression analysis was used to asses the HR for OS by facility type, and adjusted on multivariate analysis for age, sex, race, insurance, time to treatment, and use of autologous transplant. Results Of the 179,769 MM patients available, 42.4% were treated at ACs (p<0.05). Patients treated at ACs were younger than those treated at NACs (mean age 64.7 years vs. 69.2 years, p 75 years of age were more often treated at NACs (35.6% vs. 20.3%, p<0.05). ACs were more likely to treat Black and other minority patients, with Black patients representing 23.5% vs. 18%, and other minorities 5.6% vs. 3.6% of patients treated at ACs vs. NACs, respectively; all p<0.05. Academic centers were more likely to treat uninsured patients (6.3% vs. 4.1%), patients on Medicaid (7.9% vs. 5.5%) as well as privately insured patients (41.5% vs. 29.6%),( all p<0.05). The majority of Medicare patients were treated at NACs (60.8%), p<0.05. The time from diagnosis to treatment was longer at ACs, at 32.4 vs. 26.5 days (p<0.05), and patients were more likely to receive autologous stem cell transplant as first line treatment at ACs (6.3% vs 2.2%, p<0.05). While clinical trial data is limited in the NCDB, the majority of the 495 patients treated under a clinical trial were treated at ACs (393 vs 102, or 0.5% vs 0.1% of patients treated at ACs vs NACs, p<0.05). Median OS at ACs was significantly longer than at NACs, with median OS of 67.8 months (95% CI 66.89-68.79 months) compared to 38.6 months (95% CI 38.15-39.13 months) at NACs, p<0.05. One year OS was 75% vs 61%, 5-year OS 48% vs 33%, and 10-year OS of 22% vs 12% at ACs vs NACs, respectively; p<0.05. When adjusted for age, gender, race, insurance, time to treatment, and use of autologous transplant on Cox Regression analysis, the improvement in OS remained. Patients treated at AC had hazard ratio of 0.77 for all-cause mortality (95% CI 0.756-0.784) when referenced to NACs on multivariate analysis (p<0.05). Conclusion Patients with MM had significantly improved survival when treated at academic centers compared to all other facility types. The improvement in OS remained when controlled for available treatment and demographic features. Multiple factors, including specialized care, trial enrollment, and early access to autologous stem cell transplant may contribute to these improvements. Further investigations into the factors contributing to such disparities are required to standardize care and improve overall outcomes.