Treatment at safety net cancer center may overcome racial disparities in DLBCL outcomes
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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
Reference:
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.
Perspective
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Ann F. Mohrbacher, MD
This study sends an important health equity message; it is a positive example of how when things work correctly, outcomes become more equitable. The study raises questions about the inequitable distribution of insurance in our country geographically, and it also raises the question of whether we can improve equity with navigators, or by ensuring everyone at least has some basic insurance.
Using data from their center, the researchers evaluated Caucasians vs. non-Caucasians, which is a broad group of patients. They observed almost no biological differences between the distribution of the population — the patients demonstrated the same risk factors by International Prognostic Index score, they had a similar stage of disease, and there were equal proportions of patients with double-hit disease. These factors imply that coming in late to seek treatment did not contribute to differences in outcomes. Further, researchers observed that similar proportions of Caucasians and non-Caucasians received chemotherapy, the same proportion developed relapsed/refractory disease, and actually a slightly larger proportion of non-Caucasians went on to stem cell transplant. Further, similar proportions of patients had insurance.
Historically, there are data that show minority patients do worse; the researchers quote studies published in 2010 and 2014 in their comparisons. They also comment that uninsured patients have worse survival than insured patients. These data are just a few years old, but we live in a different era now, one with universal health care coverage. Given that the biology was the same, and the outcomes were the same, what is the difference? The difference is that it’s 9 years later, after the implementation of the Affordable Care Act. It has been shown in other diseases, such as multiple myeloma, that the racial differences in outcomes between African-Americans and Caucasians are no longer apparent since the ACA.
If we scale this question up to a national level, and we look at states where there is liberal availability of insurance vs. states without such availability, do you see those differences persist in states that have made insurance universally available? This is the biggest barrier in access to care. The differences in outcomes are not related to disease biology, but rather that patients don’t have access to care.
Another aspect to consider is that given that these data were derived from a very high-quality single center, it already selects, in some respects, for a type of patient population. You may already be a slightly more motivated patient if you chose to go to this center. It’s true that they serve the public in general, but there also is an enrichment of people who are highly motivated and know that this is a good place to seek treatment, and those are patients who often take better care of themselves in the first place. This could be why they didn’t see as much disparity at their center compared with what you might see at a county hospital.
I was impressed to hear they had 80% utilization of nurse navigators; that is practically unheard of. But, it may be difficult to apply such a model community-wide and easier to implement in concentrated centers. Moreover, if you have to pick and choose where to put your effort, it may be wise to put your navigators on more complicated disease models. Large cell lymphoma is a one-size-fits-all treatment that doesn’t require a lot of sophistication. Patients don’t have to apply for an expensive drug with an expensive co-pay. This is a simple, clean model, which is nice, because it tells you that such an approach is feasible.
Nurse navigators make sure patients come in, understand their disease, obtain insurance and are assisted through the co-pay system. It’s undeniable that navigators make things better, particularly in more complex care models. But, the most effective, bottom-line way to get more equal outcomes among patients is to put insurance in place.
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