Lower socioeconomic status is independently associated with shorter survival in Hodgkin Lymphoma patients—An analysis from the Brazilian Hodgkin Lymphoma Registry

Abstract

Socioeconomic status (SES) is a well-known determinant of outcomes in cancer. The purpose of this study was to analyze the impact of the SES on the outcomes of Hodgkin lymphoma (HL) patients from the Brazilian Prospective HL Registry. SES stratification was done using an individual asset/education-based household index. A total of 624 classical HL patients with diagnosis from January/2009 to December/2014, and treated with ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine), were analyzed. The median follow-up was 35.6 months, and 33% were classified as lower SES. The 3-year progression- free survival (PFS) in higher and lower SES were 78 and 64% (p < 0.0001), respectively. The 3-year overall survival (OS) in higher and lower SES were 94 and 82% (p < 0.0001), respectively. Lower SES patients were more likely to be ≥ 60 years (16 vs. 8%, p = 0.003), and to present higher risk International Prognostic score (IPS) (44 vs. 31%, p = 0.004) and advanced disease (71 vs. 58%, p = 0.003). After adjustments for potential confounders, lower SES remained independently associated with poorer survival (HR = 3.12 [1.86-5.22] for OS and HR = 1.66 [1.19-2.32] for PFS). The fatality ratio during treatment was 7.5 and 1.3% for lower and higher SES (p = 0.0001). Infections and treatment toxicity accounted for 81% of these deaths. SES is an independent factor associated with shorter survival in HL in Brazil. Potential underlying mechanisms associated with the impact of SES are delayed diagnosis and poorer education. Educational and socio-economic support interventions must be tested in this vulnerable population.

Contemporary Outcomes for Advanced-Stage Classical Hodgkin Lymphoma in the U.S.: Analysis of Surveillance, Epidemiology, and End Results Database

“…This correlates with our present study, which shows inferior survival in minorities as compared with whites. Our study also demonstrated that marital status influenced the outcomes, with married patients having a significantly better survival, highlighting the role of support system and other nonbiological factors in determining the outcomes of HL . Rectifying the differences in clinical outcomes among these numerous socioeconomic variables remains an unmet need in classical HL.…”

Education Level as a Predictor of Survival in Patients with Multiple Myeloma

“…Gustav Linder et al found that high education levels were associated with a greater probability of being offered curative treatment and improved survival in esophageal and gastroesophageal junctional cancer in Sweden; the reason may be communication difficulties and a lack of understanding of treatment, which were more commonly reported in groups with low education levels [25]. Irene Biasoli et al found that the median time from the onset of symptoms to diagnosis was longer in patients with fewer years of schooling, and a higher number of fatal events occurred in patients with low education levels [26].…”

“…In addition, patients with low education have more complications. Low education levels might undermine the patient's initiative to seek healthcare services, leading to a delay in the diagnosis of a primary disease or a life-threatening complication [26,29].…”

Resources-Stratified Guidelines for Classical Hodgkin Lymphoma

“…HL is a highly curable disease by current treatment modalities with a reported 5 years survival of 90% in 2015 in the United States [6]. Reports issued from lower income countries however suggest poorer outcomes in resource-constrained settings [7][8][9][10][11]. Limited availability of diagnostic facilities, imaging modalities and cancer treatment resources, limited access to treatment due to financial, cultural and geographic barriers, and more advanced stage at diagnosis all contribute to this disparity in survival amongst these patient populations [7][8][9].…”

“…The reported toxicity profile of this regimen issued from studies carried out in high resources settings is acceptable with rates of grade 3-4 neutropenia of 30-34%, low rates of severe infections (2%) and treatment related mortality [22]. Of note, comparably higher rates of treatment related mortality, in part due to high rates of severe infectious complications amongst lower socio-economic groups, have been reported with ABVD chemotherapy in low resource settings [10]. This regimen can be safely administered without the need of neutrophil growth factor support [23], with the exception of patients >60 years old and of vulnerable populations in low resources settings where this should be more closely considered.…”