Impact of Treatment and Insurance on Socioeconomic Disparities in Survival after Adolescent and Young Adult Hodgkin Lymphoma: A Population-Based Study

Abstract

Background: Previous studies documented racial/ethnic and socioeconomic disparities in survival after Hodgkin lymphoma among adolescents and young adults (AYA), but did not consider the influence of combined-modality treatment and health insurance.

Methods: Data for 9,353 AYA patients ages 15 to 39 years when diagnosed with Hodgkin lymphoma during 1988 to 2011 were obtained from the California Cancer Registry. Using multivariate Cox proportional hazards regression, we examined the impact of sociodemographic characteristics [race/ethnicity, neighborhood socioeconomic status (SES), and health insurance], initial combined-modality treatment, and subsequent cancers on survival.

Results: Over the 24-year study period, we observed improvements in Hodgkin lymphoma-specific survival by diagnostic period and differences in survival by race/ethnicity, neighborhood SES, and health insurance for a subset of more recently diagnosed patients (2001-2011). In multivariable analyses, Hodgkin lymphoma-specific survival was worse for Blacks than Whites with early-stage [HR: 1.68; 95% confidence interval (CI): 1.14-2.49] and late-stage disease (HR: 1.68; 95% CI, 1.17-2.41) and for Hispanics than Whites with late-stage disease (HR: 1.58; 95% CI, 1.22-2.04). AYAs diagnosed with early-stage disease experienced worse survival if they also resided in lower SES neighborhoods (HR: 2.06; 95% CI, 1.59-2.68). Furthermore, more recently diagnosed AYAs with public health insurance or who were uninsured experienced worse Hodgkin lymphoma-specific survival (HR: 2.08; 95% CI, 1.52-2.84).

Conclusion: Our findings identify several subgroups of Hodgkin lymphoma patients at higher risk for Hodgkin lymphoma mortality.

Impact: Identifying and reducing barriers to recommended treatment and surveillance in these AYAs at much higher risk of mortality is essential to ameliorating these survival disparities.

Figure 1

Percentage (%) of adolescent and young adult Hodgkin lymphoma patients undergoing radiation therapy by year of diagnosis, California, 1988–2011.

Figure 2

Kaplan-Meier curve of Hodgkin lymphoma (HL)-specific survival in adolescent and young adult patients, by combined-modality therapy and stage of disease (stage I/II, stage III/IV), California, 1988–2011. The vertical axis represents survival probability; the horizontal axis represents survival time in years. Combined-modality therapy (dotted black line), radiation therapy only (solid black line), chemotherapy only (dotted grey line), no or unknown therapy (solid grey line).