Comparative outcomes of adult T-cell leukemia/lymphoma in academic and community cancer programs

Abstract

Abstract Background: Adult T-cell leukemia/lymphoma (ATL) is an aggressive malignancy of mature CD4+ T-lymphocytes. It is associated with infection with the retrovirus human T-lymphotrophic virus type 1 (HTLV-1), highly endemic in Japan, sub-Saharan Africa, and the Caribbean (Arch Pathol Lab Med PMID: 24476526). Most cases in the United States are primarily seen in immigrants from these countries (Arch Pathol Lab Med PMID: 24476526). The acute leukemia and the lymphoma subtypes are the most common ATL presentations, with an extremely poor median overall survival of less than 1 year (Curr Treat Options Oncol PMID: 37300656). Given the complexity of ATL, outcomes may vary significantly based on the healthcare setting. Our study aims to compare clinical outcomes of ATL patients treated at academic cancer programs (ACP) versus (vs.) those treated at community cancer programs (CCP). Materials and Methods: The National Cancer Data Base was used to identify ATL cases in the United States between the years 2004 and 2022. Demographics and clinical and outcomes data were compared between patients treated at ACP and CCP. ACPs included academic and research programs, including NCI-designated comprehensive cancer centers. CCPs comprised community, comprehensive community, and integrated network cancer programs. Kaplan-Meier and Cox proportional hazards models were utilized to compare overall survival (OS) adjusting for age, ethnicity/race, insurance status, distance from treating facility, and Charlson-Deyo Score (comorbidity score). Results: A total of 3,807 ATL patients were identified, with 1,400 (37%) treated at an ACP and 595 (16%) treated at a CCP. Facility type was unavailable for 1812 patients (47%). The patients were predominantly male (58% ACP and 59% CCP) and white (63% ACP and 71% CCP). As compared to CCP, those at ACP were younger (median age 56 compared to 60, p < 0.001) and were more often diagnosed at stage IV (37% at ACP and 33% at CCP, p < 0.001). ACP centers had a higher proportion of Hispanic patients (8% vs. 6%, p < 0.001) and HIV+ patients (0.9% vs. 0.3%, p < 0.001). Private insurance was the most common primary payer in both groups (51% at ACP and 42% at CCP), and there was a higher number of non-insured patients at a CCP (6% vs. 4%, p < 0.001). Comparison of the great circle distance (CROWFLY), a variable measuring the distance between a patient's residence and hospital, revealed patients at ACP resided further from the hospital center (12 miles vs. 7 miles, p < 0.001). A higher number of patients had treatment initiated at ACP centers (74%) rather than at CCP (64%) (p < 0.001). The time to start chemotherapy was faster at ACP (13 days) compared to CCP (15 days) (p < 0.001), and more patients received radiation at ACP (13%) versus CCP (11%). The time to initiate immunotherapy was faster for patients at CCP (19 days) compared to ACP (32 days) (p < 0.001). Survival analysis showed longer adjusted median survival for ATL patients at ACP compared to CCP (1.63 years vs. CCP 1.43 years, p< 0.001). Kaplan-Meier-estimates showed that across all timepoints (2, 5, and 10 years), the OS was higher at ACP than CCP, with a 2 year survival of 46% vs. 43%, 5 year survival of 35% vs. 33%, and 10 year survival of 29% vs. 25%, respectively. Conclusion: This national analysis of 3,807 patients with adult T-cell leukemia/lymphoma (ATL) demonstrates that treatment at academic cancer programs (ACP) is associated with a statistically significant survival advantage over community cancer programs (CCP). Patients at ACPs were younger, lived farther from the treating center, were more likely to be uninsured or have HIV, and had more advanced disease at diagnosis—yet still experienced lower short-term mortality and highertreatment initiation. The adjusted median overall survival was 1.63 years at ACPs vs.1.43 years at CCPs, representing a 20% relative improvement. Survival at 2, 5, and 10 years was consistently higher at ACPs. These findings suggest that ACPs offer advantages in managing rare, aggressive lymphomas like ATL, likely due to subspecialty care, access to trials, and timely therapy. Expanding ACP–CCP collaboration and access to specialized expertise may help reduce disparities and improve outcomes in this vulnerable population.