Certain patient groups may receive less intensive treatment for mantle cell lymphoma
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Patients with mantle cell lymphoma who were unmarried, had less education or had more comorbidities appeared less likely to undergo autologous hematopoietic stem cell transplantation, according to a study published in Blood Advances.
Although autologous HSCT conferred lower mortality, 40% of the Swedish population-based cohort did not undergo the procedure.
“We can see that the health care sector is lacking resources and the need for help is constantly increasing, both due to an aging population in Sweden (and also worldwide) and more possibilities/drugs developed for patients with cancer, particularly for patients with lymphoma, in recent years,” Ingrid Glimelius, MD, PhD, chief physician and researcher in the department of immunology, genetics and pathology at Uppsala University Hospital, told Healio. “In this situation, patients with less social support and sometimes lower educational level have less possibilities to have their voice heard; for example, to participate in trials with novel drugs and in getting very demanding treatments.”
Glimelius and colleagues used the Swedish Lymphoma Register to analyze data of 369 patients aged 18 to 65 years (78.1% men; 86.1% aged 50-65 years) diagnosed with mantle cell lymphoma from January 2000 to June 2014.
Using a national database to obtain information on patients’ country of birth, highest educational level and civil status, researchers investigated associations of demographic- and disease-related factors with undergoing autologous HSCT, in order to identify vulnerable groups where novel treatment concepts may be needed. Additionally, they compared survival outcomes among patients treated with and without autologous HSCT.
Overall, 221 (60%) patients underwent HSCT within 18 months, whereas the other 148 (40%) did not.
Given all the patients were aged 65 years and younger, this was a surprising finding, Glimelius said.
“Of course, not all patients should be transplanted, but we tried to identify them and exclude them from our cohort,” Glimelius said. “The lack of giving a transplantation may depend on several factors. Maybe a transplantation would have been too demanding for a group of our patients. Still, 40% was a rather high number.”
Results of an analysis adjusted by calendar year of diagnosis, age at diagnosis, sex and country of birth showed that compared with married patients, never-married patients (OR = 0.48; 95% CI, 0.26-0.88) and divorced patients (OR = 0.5; 95% CI, 0.28-0.89) were significantly less likely to undergo autologous HSCT, with a trend toward lower likelihood observed among widows and widowers (OR = 0.33; 95% CI, 0.09-1.16).
Other factors associated with significantly lower likelihood of autologous HSCT included having 9 or fewer years of schooling (vs. 10-12 years; OR = 0.53; 95% CI, 0.3-0.93) and having more comorbidities (Charlson Comorbidity Index 2+ vs. 0; OR = 0.35; 95% CI, 0.18-0.7).
“I don't know exactly why unmarried and less-educated patients got transplants less often, but I can speculate that less social support, or inadequate information, may lead to a fear —in both the patient and doctor alike — of undergoing a very demanding treatment,” Glimelius said. “It is not a matter of cost for the health care for the individual, because it is free (in Sweden) after a certain level, but rather a fear in both patients and physicians of potentially doing harm to the patient, and a misdirected belief that a less-intensive treatment will be more tolerable upfront — if, for example, you are living alone — but in the long run might lead to a lower chance of surviving.”
Overall, 145 patients died during follow-up, 113 (78%) of whom died of lymphoma.
Five of the 221 patients who underwent autologous HSCT died within 100 days, which researchers said reflected a low transplantation-related mortality rate.
Undergoing autologous HSCT was associated with a significant reduction in all-cause mortality (HR = 0.58; 95% CI, 0.4-0.85).
Researchers acknowledged that because the study included all patients within a population, it also included those who would be unfit and ineligible for trials. They also lacked data on why patients did not receive transplant.
“We still have a struggle with caring and reaching out to all individuals in a society, particularly with very demanding treatments,” Glimelius said, adding that solutions may include more inpatient beds in Sweden or improving access to specialist care at home for patients in the curative phase of their treatment.
“If the physicians would know that the patient was taken care of and could have some support, it might be slightly easier to give a more demanding treatment,” Glimelius said.
For more information:
Ingrid Glimelius, MD, PhD, can be reached at Uppsala University Hospital, Oncology Clinic, Entrance 78, 751 85 Uppsala, Sweden; email: ingrid.glimelius@igp.uu.se.
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