CLINICAL NEWS
Literature Scan
Olszewski and colleagues identified 20,600
HL patients treated with combined-modality
approach (CMT) or chemotherapy alone
between 2003 and 2011.
More than half of the population were
women (51.3%), and the majority (58.8%)
were younger than 40 years at diagnosis.
Although clinical guidelines from the
early 2000s recommend CMT in HL
patients, the researchers noted, physicians
appear to be concerned about the use of
radiation therapy and are choosing to
minimize treatment where possible. On
average, 49.5 percent of patients received
CMT, but the proportion steadily declined from 2003 to 2011 – from 59.4 to
45.2 percent. The decrease in the use of
CMT was most pronounced in younger
patients – particularly women younger
than 30 years at the time of diagnosis. It
was not significant in women over the
age of 50, or men over the age of 70.
“It appears that oncologists and
patients are uncomfortable with current
standards of care, which cure a majority of patients, but carry toxicity that is
perceived as excessive,” Dr. Olszewski
told ASH Clinical News.
Aside from classical prognostic factors
(age, stage, tumor location, histology,
and comorbidities), the researchers
found that treatment selection was
significantly influenced by gender, race,
location, and type of insurance.
• African-American patients were 16
percent less likely to receive CMT
(OR=0.84; 95% CI 0.75–0.95)
• Patients who lived more than 50 miles
away from a treatment facility were
less likely to receive CMT (OR=0.75;
95% CI 0.66–0.86)
• Uninsured patients had the lowest
odds of receiving CMT (OR=0.72;
95% CI 0.64–0.82)
• Academic and research facilities were
less likely to use CMT than community centers (OR=0.81; 95% CI
0.69–0.96)
“Our study identified particularly vulnerable groups (older patients, African
Americans, patients who are uninsured
“Oncologists
and patients are
uncomfortable
with current
standards of
care.”
—ADAM J. OLSZEWSKI, MD
22
ASH Clinical News
or with Medicaid) with lower rates of
combined modality therapy,” Dr. Olszewski said. “Oncologists should recognize
potential barriers to effective treatment,
support those pa tients in the best decision-making, and mobilize resources to
assist them during the treatment.”
Five-year overall survival (OS) and relative survival (RS) in the entire cohort were
89.6 percent and 94.3 percent, respectively.
CMT was also associated with bet-
ter OS (hazard ratio [HR] = 0.61; 95%
CI 0.53–0.70) and RS (excess HR=0.42;
95% CI 0.33–0.54), after adjustment for
guarantee-time and indication biases.
“In my opinion, the best way to change
the standard of care is to bring to the forefront novel approaches that revolutionized
treatment of relapsed/refractory HL,” he
noted, such as brentuximab vedotin and
the PD-1 inhibitors that could be integrated into CMT.
The extent to which socioeconomic factors affected treatment decisions was both
“very surprising” and “very disturbing,” he
added, “particularly because most patients
with early-stage HL are young and may be
disadvantaged by the way we have been rationing health care in the United States.” ●
References
• Olszewski AJ, Shrestha R, Castillo JJ. Treatment selection and outcomes in
early-stage classical Hodgkin lymphoma: analysis of the National Cancer
Data Base. J Clin Oncol. 2015 January 12. [Epub ahead of print]