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Kirchhoff AC, Waters AR, Chevrier A, Wolfson JA. Access to Care for Adolescents and Young Adults With Cancer in the United States: State of the Literature. J Clin Oncol 2024; 42:642-652. [PMID: 37939320 DOI: 10.1200/jco.23.01027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/18/2023] [Accepted: 09/01/2023] [Indexed: 11/10/2023] Open
Abstract
Access to care remains a persistent challenge for adolescents and young adults (AYAs) with cancer. We review key findings in the science to date. (1) Location of care matters. There is survival benefit for AYAs treated either at a pediatric center or site with special status (eg, Children's Oncology Group, National Cancer Institute [NCI]-designated Comprehensive Cancer Center). (2) Socioeconomic status and insurance require further investigation. Medicaid expansion has had a moderate effect on AYA outcomes. The dependent care expansion benefit has come largely from improvements in coverage for younger populations whose parents have insurance, while some subgroups likely still face insurance gaps. (3) Clinical trial enrollment remains poor, but access may be improving. Numerous barriers and facilitators of clinical trial enrollment include those that are system level and patient level. NCI has established several initiatives over the past decade to improve enrollment, and newer collaboratives have recently brought together multidisciplinary US teams to increase clinical trial enrollment. (4) Effective AYA programs require provider and system flexibility and program reflection. With flexibility comes a need for metrics to assess program effectiveness in the context of the program model. Centers treating AYAs with cancer could submit a subset of metrics (appropriate to their program and/or services) to maintain their status; persistence would require an entity with staying power committed to overseeing the metrics and the system. Substantial clinical and biological advances are anticipated over the next 20 years that will benefit all patients with cancer. In parallel, it is crucial to prioritize research regarding access to health care and cancer care delivery; only with equitable access to care for AYAs can they, too, benefit from these advances.
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Affiliation(s)
- Anne C Kirchhoff
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Cancer Control and Population Sciences, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT
| | - Austin R Waters
- Cancer Control and Population Sciences, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Amy Chevrier
- Cancer Control and Population Sciences, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT
| | - Julie A Wolfson
- Division of Pediatric Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
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Keegan THM, Abrahão R, Alvarez EM. Survival Trends Among Adolescents and Young Adults Diagnosed With Cancer in the United States: Comparisons With Children and Older Adults. J Clin Oncol 2024; 42:630-641. [PMID: 37883740 DOI: 10.1200/jco.23.01367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/20/2023] [Accepted: 08/17/2023] [Indexed: 10/28/2023] Open
Abstract
PURPOSE Although data from 1975 to 1997 revealed a gap in cancer survival improvement in adolescents and young adults (AYAs; 15-39 years) compared with children and older adults, more recent studies have reported improvements in AYA cancer survival overall. The current analysis provides an update of 5-year relative survival and cancer survival trends among AYAs compared with children and older adults. METHODS We obtained data from the National Cancer Institute Surveillance, Epidemiology, and End Results Program for 17 regions to obtain recent (2010-2018) 5-year relative survival estimates by cancer type, stage, sex, and race/ethnicity by age group. In addition, we calculated 5-year relative survival trends during 2000-2014. RESULTS Across 33 common AYA cancers, AYAs and children had high 5-year relative survival (86%) and experienced similar survival improvements over time (average absolute change: AYAs, 0.33%; children 0.36%). Among AYAs, 73% of cancers had improvement in 5-year relative survival since 2000. Despite this overall progress, we identified cancers where survival was worse in AYAs than younger or older patients and cancers that have had either a lack of improvement (osteosarcoma and male breast) or decreases in survival (cervical and female bladder) over time. Furthermore, males had inferior survival to females for all cancers, except Kaposi sarcoma and bladder cancer, and non-Hispanic Black/African American AYAs experienced worse survival than other racial/ethnic groups for many cancers considered in this study. CONCLUSION Future studies should focus on identifying factors affecting survival disparities by age, sex, and race/ethnicity. Differences in biology, clinical trial enrollment, delivery of treatment according to clinical guidelines, and supportive and long-term survivorship care may account for the survival disparities we observed and warrant further investigation.
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Affiliation(s)
- Theresa H M Keegan
- Division of Hematology and Oncology, Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | - Renata Abrahão
- Division of Hematology and Oncology, Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | - Elysia M Alvarez
- Division of Pediatric Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA
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Parsons SK, Keegan THM, Kirchhoff AC, Parsons HM, Yabroff KR, Davies SJ. Cost of Cancer in Adolescents and Young Adults in the United States: Results of the 2021 Report by Deloitte Access Economics, Commissioned by Teen Cancer America. J Clin Oncol 2023:JCO2201985. [PMID: 36827624 DOI: 10.1200/jco.22.01985] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
Abstract
PURPOSE The purpose of this report, commissioned by Teen Cancer America and performed by Deloitte Access Economics in 2021, was to estimate the total costs incurred by adolescent and young adults (AYAs) after cancer diagnosis in the United States (US) over their life course. METHODS The incidence of cancer in 2019 among AYAs age 15-39 years was estimated from the US Cancer Statistics Public Use Database, and relative survival was projected from the Surveillance, Epidemiology, and End Results Program. Cost domains included health system, productivity, and well-being costs. Components were estimated with published literature and pooled data from the Medical Expenditure Panel Survey from 2008 to 2012 and inflated to 2019 dollars. RESULTS The economic and human costs of cancer in AYAs are substantial-$23.5 billion overall, corresponding to $259,324 per person over the lifetime. The majority of costs are borne by AYA cancer survivors themselves in the form of lost productivity, loss of well-being, and loss of life. CONCLUSION These findings underscore the need to address the burden of cancer in AYAs through targeted programs for AYAs, such as financial navigation and health insurance literacy interventions, as well as local and national policy initiatives to address access to and enhanced coverage for clinical trials participation, fertility services, and survivorship care.
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Affiliation(s)
- Susan K Parsons
- Divisions of Hematology/Oncology and Clinical Care Research, Tufts Medical Center, Tufts University School of Medicine, Boston, MA.,Departments of Medicine and Pediatrics, Tufts University School of Medicine, Boston, MA
| | - Theresa H M Keegan
- Center for Oncology Hematology Outcomes Research and Training and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA
| | - Anne C Kirchhoff
- Huntsman Cancer Institute and University of Utah, School of Medicine, Salt Lake City, UT
| | - Helen M Parsons
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN
| | - K Robin Yabroff
- Scientific Vice President, Health Services Research, American Cancer Society, Inc
| | - Simon J Davies
- Executive Director, Teen Cancer America, Los Angeles, CA
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Berkman AM, Choi E, Salsman JM, Peterson SK, Cheung CK, Andersen CR, Lu Q, Livingston JA, Hildebrandt MAT, Parsons SK, Roth ME. Excess risk of chronic health conditions in Hispanic survivors of adolescent and young adult cancers. J Cancer Surviv 2023:10.1007/s11764-023-01342-z. [PMID: 36750493 DOI: 10.1007/s11764-023-01342-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/23/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE There is a growing population of survivors of adolescent and young adult (AYA) cancers (age 15-39 years at diagnosis). Studies in AYA cancer survivors have identified racial and ethnic disparities in long-term outcomes. To understand the extent to which a cancer diagnosis exacerbates pre-existent health disparities within a minoritized population, comparisons should be made to those of the same race or ethnicity without a cancer history. METHODS Self-reported data from the National Health Interview Survey (2009-2018) were used to identify Hispanic AYA cancer survivors and Hispanic age- and sex-matched controls. SES factors (marital status, income, education, insurance) and prevalence of chronic health conditions were compared between groups using chi-square tests. The log-odds of chronic conditions were modeled by survey-weighted logistic regression with relation to age at survey, sex, marital status, education, family income, and cancer group (control versus cancer), together with interactions between each variable and cancer group (survivors vs. controls). RESULTS Five hundred thirty-nine survivors and 5390 controls were included. Compared with controls, survivors were less likely to be married and have family income > 45 K/year, and more likely to be insured and have completed some college. Survivors had higher odds than controls of chronic health conditions (odds ratio (OR): 7.39, p < 0.001 for at least 1 and OR: 4.78, p < 0.001 for 3 or more) including cardiovascular disease, diabetes, and hypertension. Female sex, higher educational attainment, and public insurance were each associated with increased odds of chronic conditions in Hispanic AYA survivors. CONCLUSIONS An AYA cancer diagnosis is associated with poor SES outcomes and increased odds of comorbidities within the Hispanic population. IMPLICATIONS FOR CANCER SURVIVORS Cancer history can exacerbate underlying health disparities. Screening for chronic conditions is especially important in minoritized populations.
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Affiliation(s)
- Amy M Berkman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Eunju Choi
- Department of Nursing, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John M Salsman
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Susan K Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Clark R Andersen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Qian Lu
- Department of Health Disparities Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Institute, Houston, TX, USA
| | - J A Livingston
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michelle A T Hildebrandt
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan K Parsons
- Institute for Clinical Research and Health Policy Studies and the Division of Hematology/Oncology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Michael E Roth
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Roth M, Berkman A, Andersen CR, Cuglievan B, Andrew Livingston J, Hildebrandt M, Bleyer A. Improved Survival of Young Adults with Cancer Following the Passage of the Affordable Care Act. Oncologist 2022; 27:135-143. [PMID: 35641206 PMCID: PMC8895735 DOI: 10.1093/oncolo/oyab049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/05/2021] [Indexed: 12/04/2022] Open
Abstract
Background Compared with their ensured counterparts, uninsured adolescents and young adults (AYAs) with cancer are more likely to present with advanced disease and have poor prognoses. The Patient Protection and Affordable Care Act (ACA), enacted in 2010, provided health care coverage to millions of uninsured young adults by allowing them to remain on their parents’ insurance until age 26 years (the Dependent Care Expansion, DCE). The impact of the expansion of insurance coverage on survival outcomes for young adults with cancer has not been assessed. Participants Utilizing the Surveillance, Epidemiology, and End Results database, we identified all patients aged 12-16 (younger-AYAs), 19-23 (middle-AYAs), and 26-30 (older-AYAs) who were diagnosed with cancer between 2006-2008 (pre-ACA) and 2011-2013 (post-ACA). Methods In this population-based cohort study, we used an accelerated failure time model to assess changes in survival rates before and after the enactment of the ACA DCE. Results Middle-AYAs ages 19-23 (thus eligible to remain on their parents’ insurance) experienced significantly increased 2-year survival after the enactment of the ACA DCE (survival time ratio 1.25, 95% confidence interval: 0.75-2.43, P = .029) and that did not occur in younger-AYAs (ages 12-16). Patients with sarcoma and acute myeloid leukemia accounted for the majority of improvement in survival. Middle-AYAs of hispanic ethnicity and those with low socioeconomic status experienced trends of improved survival after the ACA DCE was enacted. Conclusion Survival outcomes improved for young adults with cancer following the expansion of health insurance coverage. Efforts are needed to expand coverage for the millions of young adults who do not have health insurance.
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Affiliation(s)
- Michael Roth
- Division of Pediatrics and Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy Berkman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Clark R Andersen
- Division of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Branko Cuglievan
- Division of Pediatrics and Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Andrew Livingston
- Division of Pediatrics and Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michelle Hildebrandt
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Archie Bleyer
- Department of Radiation Medicine, Oregon Health and Science University, Portland, OR, USA
- Department of Pediatrics, McGovern Medical School, University of Texas, TX, USA
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Abrahão R, Cooley JJP, Maguire FB, Parikh-Patel A, Morris CR, Schwarz EB, Wun T, Keegan THM. Stage at diagnosis and survival among adolescents and young adults with lymphomas following the Affordable Care Act implementation in California. Int J Cancer 2021; 150:1113-1122. [PMID: 34800045 DOI: 10.1002/ijc.33880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/27/2021] [Accepted: 11/10/2021] [Indexed: 12/19/2022]
Abstract
Adolescents and young adults (AYAs, 15-39 years) are the largest uninsured population in the Unites States, increasing the likelihood of late-stage cancer diagnosis and poor survival. We evaluated the associations between the Affordable Care Act (ACA), insurance coverage, stage at diagnosis and survival among AYAs with lymphoma. We used data from the California Cancer Registry linked to Medicaid enrollment files on AYAs diagnosed with a primary non-Hodgkin (NHL; n = 5959) or Hodgkin (n = 5378) lymphoma pre-ACA and in the early and full ACA eras. Health insurance was categorized as continuous Medicaid, discontinuous Medicaid, Medicaid enrollment at diagnosis/uninsurance, other public and private. We used multivariable regression models for statistical analyses. The proportion of AYAs uninsured/Medicaid enrolled at diagnosis decreased from 13.4% pre-ACA to 9.7% with full ACA implementation, while continuous Medicaid increased from 9.3% to 29.6% during this time (P < .001). After full ACA, AYAs with NHL were less likely to be diagnosed with Stage IV disease (adjusted odds ratio [aOR] = 0.84, 95% confidence interval [CI] = 0.73-0.97). AYAs with lymphoma were more likely to receive care at National Cancer Institute-Designated Cancer Centers (aOR = 1.42, 95% CI = 1.28-1.57) and had lower likelihood of death (adjusted hazard ratio = 0.54, 95% CI = 0.46-0.63) after full ACA. However, AYAs from the lowest socioeconomic neighborhoods, racial/ethnic minority groups and those with Medicaid continued to experience worse survival. In summary, AYAs with lymphomas experienced increased access to healthcare and better clinical outcomes following Medicaid expansion under the ACA. Yet, socioeconomic and racial/ethnic disparities remain, calling for additional efforts to decrease health inequities among underserved AYAs with lymphoma.
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Affiliation(s)
- Renata Abrahão
- Center for Healthcare Policy & Research, University of California Davis, Sacramento, California, USA.,Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Julianne J P Cooley
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Frances B Maguire
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Arti Parikh-Patel
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Cyllene R Morris
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Eleonor Bimla Schwarz
- Center for Healthcare Policy & Research, University of California Davis, Sacramento, California, USA
| | - Ted Wun
- Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Theresa H M Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
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Berkman AM, Andersen CR, Puthenpura V, Livingston JA, Ahmed S, Cuglievan B, Hildebrandt MAT, Roth ME. Disparities in the long-term survival of adolescent and young adult diffuse large B cell lymphoma survivors. Cancer Epidemiol 2021; 75:102044. [PMID: 34597882 DOI: 10.1016/j.canep.2021.102044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE The population of adolescent and young adult (AYA, ages 15-39 years) diffuse large B-cell lymphoma (DLBCL) survivors is growing, however long-term overall survival patterns and disparities are largely unknown. METHODS The current study utilized the Surveillance, Epidemiology, and End Results (SEER) registry to assess the impact of race/ethnicity, sex, socioeconomic status, and rurality on long-term survival in 5-year DLBCL survivors using an accelerated failure time model. RESULTS Included were 4767 5-year survivors of AYA DLBCL diagnosed between the years 1980 and 2009 with a median follow-up time of 13.4 years. Non-Hispanic Black survivors had significantly worse long-term survival than non-Hispanic White survivors (Survival Time Ratio (STR): 0.53, p < 0.0001). Male sex (STR: 0.57, p < 0.0001) and older age at diagnosis were also associated with reduced long-term survival. There was no evidence that survival disparities improved over time. CONCLUSIONS Racial disparities persist well into survivorship among AYA DLBCL survivors. Studies investigating specific factors associated with survival disparities are urgently needed to better address these disparities.
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Affiliation(s)
- Amy M Berkman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Clark R Andersen
- Division of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vidya Puthenpura
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - J A Livingston
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sairah Ahmed
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Branko Cuglievan
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michelle A T Hildebrandt
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael E Roth
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Kahn JM, Maguire FB, Li Q, Abrahão R, Flerlage JE, Alvarez E, Keegan THM. Initial cancer treatment and survival in children, adolescents, and young adults with Hodgkin lymphoma: A population-based study. Cancer 2021; 127:4613-4619. [PMID: 34494662 DOI: 10.1002/cncr.33868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hodgkin lymphoma (HL) is a treatable tumor affecting children, adolescents and young adults (AYAs; 15-39 years old). Population-based studies report worse survival for non-White children and AYAs but have limited data on individual therapeutic exposures. This study examined overall and HL-specific survival in a population-based cohort of patients while adjusting for sociodemographic factors and treatment. METHODS Data for 4807 patients younger than 40 years with HL (2007-2017) were obtained from the California Cancer Registry. Individual treatment information was extracted from text fields; chemotherapy regimens were defined by standard approaches for pediatric and adult HL. Multivariable Cox models examined the influence of patient and treatment factors on survival. RESULTS At a median follow-up of 4.4 years, 95% of the patients were alive. Chemotherapy differed by age, with 70% of 22- to 39-year-olds and 41% of <22-year-olds receiving doxorubicin, bleomycin, vinblastine, and dacarbazine (P < .001). In multivariable models, older patients (22-39 vs < 21 y; hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.11-2.10), Black (vs White patients); HR, 1.90; 95% CI, 1.25-2.88), and Hispanic patients (HR, 1.45; 95% CI, 1.06-1.99) experienced worse survival; among those < 21 y, Black race was associated with a 3.3-fold increased risk of death (HR, 3.26; 95% CI, 1.43-7.42). CONCLUSIONS In children and AYAs with HL, older age and non-White race/ethnicity predicted worse survival after adjustments for treatment data. Further work is needed to identify the biological and nonbiological factors driving disparities in these at-risk populations.
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Affiliation(s)
- Justine M Kahn
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Frances B Maguire
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, California
| | - Qian Li
- Center for Oncology Hematology Outcomes Research and Training and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, California
| | - Renata Abrahão
- Center for Oncology Hematology Outcomes Research and Training and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, California.,Center for Healthcare Policy and Research, University of California Davis School of Medicine, Sacramento, California
| | - Jamie E Flerlage
- Center for Healthcare Policy and Research, University of California Davis School of Medicine, Sacramento, California.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Elysia Alvarez
- Center for Oncology Hematology Outcomes Research and Training and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, California.,Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California
| | - Theresa H M Keegan
- Center for Oncology Hematology Outcomes Research and Training and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, California
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