Treatment at safety net cancer center may overcome racial disparities in DLBCL outcomes
ORLANDO — White and nonwhite patients with de novo diffuse large B-cell lymphoma treated at a safety net cancer center demonstrated similar survival outcomes, despite nonwhite patients having poorer health insurance coverage, according to study results presented at ASH Annual Meeting and Exposition.
Among those with relapsed/refractory disease, a similar proportion of white and nonwhite patients underwent stem cell transplantation and were enrolled on a clinical trial, results showed.
Researchers attributed these results to the availability of a patient navigator program, which more than 80% of the study population utilized.
“We utilize disease-based navigators, which really helps ensure the navigators are familiar with the disease and the patients,” Nilanjan Ghosh, MD, PhD, chief of the lymphoma division at Levine Cancer Institute of Atrium Health, told Healio. “That establishes a direct communication between the patient and the navigator. When you have a point-of-care person that can help navigate care, patients feel comforted. The navigators are essential to help coordinate care, work with social workers to arrange for transportation and lodging benefits for those in need, and negotiate support for medications through the pharmacy group. It’s their hard work that contributes to equal outcomes.”
Although DLBCL is the most common and potentially curable type of non-Hodgkin lymphoma, prior studies have shown that outcomes disparities are prevalent in this patient population.
“Unfortunately, several studies have shown that minorities have worse outcomes when compared with their Caucasian counterparts,” lead study author Bei Hu, MD, lymphoma physician at Levine Cancer Institute, said during her presentation. “Additionally, uninsured and Medicaid patients with DLBCL have inferior survival outcomes compared with those with private insurance. Although there has been a boon in research for oncological care, minorities are often underrepresented in clinical trials.”
Survival disparities between minority patients and Caucasians can be due to two reasons, Ghosh said.
“This can be due to differences in prognostic markers,” he told Healio. “Another hypothesis is that this is due to a difference in access to care. In our study we showed that the biology, at least in our cohort, was similar between the two groups. The powerful finding of our study was that when you take patients with similar biology and treat them equally, the outcomes are similar. Moreover, we showed that a similar number of minorities went on to receive transplant and enroll in clinical trials.
“Traditionally, minorities are underrepresented in clinical trials,” Ghosh added. “If you are able to provide access to care, transportation and lodging support, then you can provide equal opportunity for these minority patients to enroll in clinical trials. Our study shows how you can break the ice.”
Hu, Ghosh and colleagues analyzed data on 182 patients with de novo DLBCL who were treated at Levine Cancer Institute between 2016 and January 2019. Of the patients, 77% (n = 141; median age at diagnosis, 64 years; 50% men) were white and 23% (n = 41; median age at diagnosis, 56 years; 49% men) were nonwhite; the latter group included 73% African American, 15% Hispanic or Latino, 10% Asian and 2% other ethnicity patients.
The disease biology appeared comparable between whites and nonwhites, Hu said, as demonstrated by prognostic scores per the Revised International Prognostic Index (very good, 5% for both; good, 44%% vs. 49%; poor, 51% vs. 46%) and the proportion of patients with double-hit lymphomas (11% vs. 7%).
However, researchers observed a significant difference in insurance coverage between white and nonwhite patients (P = .014), with no white patients being uninsured compared with 7% of nonwhite patients, and 33% of white patients having private insurance compared with 27% of nonwhite patients.
Most white (96%) and nonwhite (98%) patients received a front-line anthracycline/rituximab (Rituxan; Genentech, Biogen)-based regimen.
“Only a few did not receive an anthracycline-based regimen due to poor cardiac dysfunction,” Hu said.
Median follow-up was 31.6 months.
At that time, researchers observed no difference in 2-year OS (74% vs. 81%) or PFS (60% vs. 63%) between white and nonwhite patients.
After front-line therapy, 39% of both white and nonwhite patients developed relapsed or refractory disease.
Of these patients, a similar proportion of whites and nonwhites underwent stem cell transplantation (11% vs. 20%) and enrolled on clinical trials (11% vs. 12%). Both groups received a median two treatments.
“In our study, we saw that Caucasians and non-Caucasians had similar outcomes,” Hu said. “We postulate that high utilization of our nurse navigator program and equal access to standard treatments, clinical trials and stem cell transplant can overcome some of the inferior outcomes seen in minorities in previously reported studies.”
Researchers touted their center’s patient navigator program as especially contributing to this reduction in disparities between white and nonwhite patients. Eighty-six percent of white patients and 81% of nonwhite patients in the trial received nurse navigation services.
“Nurse navigators — a relatively new aspect of oncologic care, as oncology becomes more complex — are oncology nurses who guide a patient throughout their cancer care and identify any barriers that would prevent the patient from coming to their appointments or receiving their treatments,” Hu said.
Nurse navigators can bring care closer to home for patients, Ghosh told Healio.
“Checking patients’ labs, a quick check-in visit — that can all be done at a regional site closer to the patient’s home,” he said. “We also have clinical trials open at many of our reginal sites, so patients can get enrolled locally.” – by Alexandra Todak
Hu B, et al. Abstract 425. Presented at: ASH Annual Meeting and Exposition; Dec. 7-10, 2019; Orlando.
Disclosures: Ghosh reports speakers bureau or consultant roles with an honoraria or research funding from AbbVie, AstraZeneca, Bristol-Myers Squibb, Celgene, Forty Seven Inc., Genentech, Gilead, Janssen, Pharmacyclics, SGN and TG Therapeutics. Hu reports no relevant financial disclosures. Please see the abstract for all other authors’ relevant financial disclosures.