A tale of two settings: Survival disparities in CLL/SLL between academic and community cancer programs in the u.S. national cancer database

Abstract

Abstract Background: Hematologic malignancies are managed at both academic and community-based centers. Studies across solid tumors and blood cancers suggest differences in treatment modality, intensity, and outcomes based on care setting. Chronic lymphocytic leukemia and small lymphocytic lymphoma (CLL/SLL) collectively account for approximately one-quarter of all hematologic malignancies under active treatment in the U.S. Prior research suggests that time to treatment initiation may be longer at academic centers. This analysis—leveraging over 200,000 patients—represents the largest published cohort of CLL/SLL and evaluates whether treatment timing and survival outcomes vary by facility type, with emphasis on sociodemographic differences such as race, ethnicity, and insurance status. Methods: We conducted a retrospective analysis of patients diagnosed with CLL/SLL between 2004 and 2022 using the National Cancer Database. Patients were stratified by facility type: Academic Cancer Programs (ACPs), including NCI-designated and research institutions, and Community Cancer Programs (CCPs), including community, comprehensive community, and integrated network centers. Demographic, clinical, treatment, and survival data were compared. Kaplan-Meier and Cox models assessed overall survival (OS), adjusting for age, race/ethnicity, insurance, comorbidity (Charlson-Deyo score), and distance to the treating facility. Results: Among 202,069 patients, 102,545 (50.7%) were treated at ACPs and 97,704 (48.4%) at CCPs; 1,820 (0.9%) were excluded due to unknown facility type. Black patients comprised 9.2% at ACPs vs. 6.3% at CCPs, and Hispanic patients 3.4% vs. 2.3%, respectively. Age distribution differed significantly (p < 0.001): patients <60 were more common at ACPs (23.1% vs. 18.6%), and ≥75 at CCPs (37.4% vs. 31.9%). Private insurance was more common at ACPs (34.0% vs. 29.5%), while Medicare predominated at CCPs (63.0% vs. 56.7%). Medicaid and uninsured patients were more likely seen at ACPs (3.9% and 2.3% vs. 3.0% and 1.8%). Charlson-Deyo scores ≥2 were more frequent at ACPs (8.5% vs. 7.9%, p = 0.006). Median distance was longer at ACPs (10.2 vs. 7.5 miles, p < 0.001), indicating patients may have bypassed nearby facilities to seek care at academic centers. Treatment patterns differed. Watchful waiting was more common at ACPs (37.6% vs. 33.0%), and no treatment less frequent (17.2% vs. 20.9%, p < 0.001). Systemic therapy rates were similar (19.4% vs. 19.3%), but ACPs had longer median time to treatment: prescription (24 vs. 22 days), systemic therapy (33 vs. 30), chemotherapy (34 vs. 31), immunotherapy (39 vs. 36) (all p ≤ 0.004). Radiation was used in 1.0% of cases in both settings. Survival outcomes favored ACPs. Adjusted median OS was 9.38 years vs. 9.00 years. Kaplan-Meier–estimated OS at 2, 5, and 10 years was 84.3%, 69.1%, and 47.8% at ACPs, vs. 84.4%, 68.3%, and 46.1% at CCPs (p < 0.001). Multivariable Cox analysis confirmed ACPs treatment as independently associated with improved OS (HR 0.95, 95% CI: 0.93–0.97, p < 0.001). Conclusions: This comprehensive analysis—the largest of its kind—demonstrates that treatment at ACPs is associated with modest but statistically significant survival gains in CLL/SLL, despite delays to treatment and higher comorbidity burden. ACPs cared for a more diverse and socioeconomically vulnerable population, including higher proportions of Black, Hispanic, Medicaid, and uninsured patients who traveled longer distances. That these patients experienced improved survival despite increased medical complexity suggests the benefits of specialized multidisciplinary care and broader resource availability at ACPs. These findings reflect the capacity of ACPs to manage complex cases effectively, likely due to access to multidisciplinary teams, innovative therapies, and clinical research infrastructure. To improve outcomes system-wide, ACPs should consider to establish deeper partnerships with CCPs by facilitating clinical trial access, building referral pipelines, and expanding education on evidence-based guidelines. Such efforts are essential to bridging disparities, extending the reach of high-quality care, and advancing equitable delivery of CLL/SLL treatment nationwide.