There may be a hidden reason influencing treatment choices for early-stage classical Hodgkin’s Lymphoma: socioeconomic factors. In a recent study, University researchers found that type of insurance, sex and race all significantly affected the type of treatment patients received.
Headed by Assistant Professor of Medicine Adam Olszewski, the research team analyzed data from 20,600 patients taken from the National Cancer Data Base with the objective of “defin(ing) factors affecting treatment selection and resulting survival outcomes in the United States,” Olszewski said. The team’s results were published online this month in the Journal of Clinical Oncology.
Hodgkin’s Lymphoma is a cancer of the immune system that typically includes “enlargement of the lymph nodes, spleen and other immune tissue,” according to the National Cancer Institute’s website. Olszewki’s research found that Hodgkin’s Lymphoma often affects young adults, with around half of the cases are diagnosed in patients that are less than 40 years old.
Traditionally, Hodgkin’s Lymphoma patients are either treated with chemotherapy alone or combined-modality therapy — a combination of chemotherapy and radiation. The choice between the two treaments remains controversial, with 49.5 percent of the patients in the study receiving CMT.
“There are pluses and minuses for either strategy. The full course of chemo takes around six months, whereas combined-modality therapy can sometimes only take around three,” Olszewski said. “There are some risks of increased heart disease with the longer course of chemo, but CMT may increase the risk of breast cancer for young women later in life,” he added.
Though the five-year overall survival rate for Hodgkin’s Lymphoma, at 89.6, percent is relatively high compared to other cancers, the researchers found that CMT resulted in a higher survival rate than chemotherapy alone. But Olszewski’s team found that the rate at which CMT is chosen declined from 59.4 percent in 2003 to 45.2 percent in 2011. Because CMT includes radiation, this decline may be due to patients’ fear of developing cancer again later in life, Olszewski said.
Besides typical prognostic factors such as age, tumor location, histology and the presence of other illnesses, the researchers found that gender, race, distance to facility and type of insurance also played a role in treatment selection, with uninsured patients having the lowest odds of receiving CMT.
“Decisions are made to some extent on the basis of reasonable, clinical characteristics,” said Olszewski. “However, a lot of the time the decision is based off of other factors — one of them is a lack of health insurance.”
The odds of receiving CMT decreased with age, according to the study.
With regards to race, even after accounting for education, insurance and income, black patients were significantly less likely to receive CMT, according to the study. Patients with private insurance had higher odds of receiving CMT compared with those who were uninsured or who had Medicaid or Medicare coverage.
Due to its correlational nature, the research does not provide definitive answers as to why these factors affect treatment selection. But Assistant Professor of Medicine Eric Winer, who was not involved with the study, said he believes that physicians try to avoid giving younger patients radiation due to risk of future cancers. Younger patients are often also uninsured, so it appears as though uninsured patients receive CMT at a lesser rate.
Some other studies illustrate that working mothers and younger patients may have a harder time attending the daily visits required for CMT, Olszewski said. “There also may be differences in transportation — if a patient does not have a car, that might be a problem. Physicians and other people involved need to realize that younger patients need to get some support in receiving this treatment,” he added.
Winer and Olszewski both cited access to health care as incredibly important for receiving the proper treatment for Hodgkin’s Lymphoma. “The availability of the Affordable Care Act might help the situation, as might additional services that hospitals and other health care centers can provide. Treatment does not just involve the doctor and the patient,” Olszewski said.
“Olszewski’s research was exceptional in terms of the data analysis completed,” Winer said, adding that the study was “quite reliable” due to the team’s methodology.
Winer said the team’s next step should be to find novel therapies that can potentially remove radiation from treatment in a safe manner or to undertake further clinical trials to figure out the best mechanism to treat Hodgkin’s Lymphoma, .
One new strategy may be immune therapy, which includes the administration of drugs that invigorate the immune system to destroy the cancer itself, Olszewski said. These drugs often have remarkable results in people who are not responding to other treatments, he added.
