Curable but not equal: Survival disparities in classic Hodgkin lymphoma by treatment facility type in the United States

Abstract

Abstract Background: Classic Hodgkin lymphoma (cHL) has an estimated global incidence of 85,000 cases annually and primarily affects adolescents and young adults (Hematol Oncol PMID: 38037872). The advent of targeted therapies and immunotherapy has led to substantial improvements in clinical outcomes. However, these advances may not be equitably accessed across healthcare systems. Real-world disparities in comprehensive care, diagnostic evaluation, multidisciplinary coordination, and clinical trial participation may contribute to survival differences, especially for patients treated in community settings (Front Public Health PMID: 37920585). While prior studies have assessed population-level outcomes in cHL, national-level comparisons of clinical characteristics and long-term survival based on treatment facility type remain limited. This study represents the largest national retrospective analysis to date evaluating the impact of treatment facility -Academic Cancer Programs (ACPs) versus Community Cancer Programs (CCPs) - on demographics, treatment patterns, and survival outcomes in patients with cHL. Methods: We conducted a retrospective analysis of patients diagnosed with cHL in the U.S. between 2004 and 2022 using the National Cancer Database. Patients were categorized by facility type: ACPs included academic and research programs (including NCI-designated centers), while CCPs included community, comprehensive community, and integrated network cancer programs. Demographic, clinical, and treatment characteristics were compared across cohorts. Kaplan-Meier and Cox proportional hazards models were used to evaluate overall survival (OS), adjusting for age, race/ethnicity, insurance, Charlson-Deyo comorbidity score, and distance from treating facility. Results: Among 101,190 patients with cHL, 28,566 (28%) were treated at ACPs and 23,699 (23%) at CCPs; 48,925 with unspecified facility data were excluded from comparative analysis. ACP-treated patients were younger (median age: 58 vs. 60 years, P<0.001), more likely to be Black (13% vs. 9%) or Hispanic (10% vs. 8%), and more often had private insurance (49% vs. 42%). The majority lived in metropolitan areas (84% ACP vs. 80% CCP). Stage II was most common in both cohorts (29% ACP vs. 30% CCP), followed by stage IV (27% vs. 23%, P<0.001), suggesting more advanced disease at ACPs. Comorbidity profiles were similar (Charlson-Deyo 0–1: 90% ACP vs. 89% CCP). Systemic treatment was more common at ACPs (65% vs. 61%), while radiation was more frequent at CCPs (22% vs. 19%, P<0.001). Patients treated at ACPs had superior OS at all time points: 2-year (79% vs. 77%), 5-year (70% vs. 69%), and 10-year (58% vs. 56%). Median adjusted OS was longer at ACPs (14 vs. 13 years, P<0.001), and median follow-up time was longer (47 vs. 41 months). Differences remained statistically significant in multivariable models. Conclusions: In this large, nationally representative cohort, treatment at ACP was associated with improved long-term survival in patients with cHL, even though ACP patients presented with more advanced disease and greater racial/ethnic diversity. These findings suggest that multidisciplinary infrastructure, disease-specific expertise, timely systemic therapy, and access to advanced diagnostics at ACPs contribute to superior outcomes. While cHL is among the most curable hematologic malignancies - with OS approaching 90% - curability does not ensure equity. Expanding access to comprehensive oncology services through academic-community partnerships, shared treatment protocols, virtual consults, and streamlined referral systems may help mitigate disparities and optimize outcomes across all care settings.