Outcomes of primary cutaneous anaplastic large cell lymphoma across u.S. cancer care settings: A national cancer database analysis.

Abstract

Abstract Background: Primary cutaneous (PC) anaplastic large cell lymphoma (-ALCL) represents 8% of cutaneous lymphoma cases. Unlike systemic ALCL, PC-ALCL follows an indolent course and has an excellent prognosis. The United States Surveillance, Epidemiology, and End Results (SEER) database reported 5- and 10-year overall survival (OS) rates of 81 and 62 percent, respectively, among 501 cases (2005 to 2016). Despite the excellent OS, it does have a propensity for relapse (5-year failure-free survival rate 55%) (Clin Exp Dermatol PMID: 34081802). Extracutaneous disease occurs in about 10% of cases, usually involving regional lymph nodes, and unlikely to involve distant lymph nodes or viscera. Historically, patients with PC-ALCL have had excellent response to local therapies (surgery or radiation) and have had no apparent benefit from multiagent chemotherapy (Arch Dermatol PMID: 19528422, Blood PMID: 18385450). This study aims to analyze the demographics, treatment patterns, and outcomes of PC-ALCL in two large cohorts: academic cancer programs (ACPs) vs community cancer programs (CCPs). Methods: We conducted a retrospective analysis of PC-ALCL cases in the United States reported to the National Cancer Database (NCDB) between 2004 and 2022. Demographic, clinical and survival data were compared between patients treated at ACPs and CCPs. and treatment characteristics were compared between patients of the two cohorts. 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 used to compare overall survival (OS), adjusting for age, race/ethnicity, insurance status, comorbidity score (Charlson-Deyo), and distance from treating facility. Results: A total of 2,618 patients with PC-ALCL were identified, with 1,523 (58%) treated at ACPs and 822 (31%) treated at CCPs. Both groups had similar male to female ratios (58:42 at ACPs, 61:39 at CCPs). CCP-treated patients were older, with a median age of 69 vs. 65 years. ACPs saw a greater proportion of patients under 60 years of age (37% vs. 26%, p<0.001). Race/ethnicity distribution showed that ACPs saw slightly more Black (14 % vs. 8%) and Hispanic (5% vs. 3%) patients compared to CCPs (p<0.001). Insurance coverage differed significantly, with CCPs seeing more Medicare-insured patients (57% vs. 49%, p<0.001). ACPs saw more patients with private insurance (41% vs. 36%), Medicaid insurance (4.6% vs. 2.9%) and uninsured patients (2.4% vs. 1.8%). Patients seen at ACPs lived further away from their treatment facility (12.3 miles vs. 9 miles). Treatment patterns showed that ACPs were more likely to manage the patients with active surveillance (4.5% vs. 2.8%), while CCPs had slightly higher rates of radiation therapy (47% vs. 41%, p<0.001). Median time-to-treatment was longer in ACPs (38 days vs. 29 days). Survival analysis showed longer adjusted median overall survival time for patients treated at CCPs (12.6 years vs. 10.8 years). Kaplan–Meier–estimated OS at 2, 5 and 10 years were similar between the two groups. For ACPs, the estimated OS at 2, 5 and 10 were 82%, 69% and 52%, and for CPPs were 81%, 69% and 57%, respectively. In a multivariable Cox model—adjusting for age, race/ethnicity, insurance status, great-circle distance to care, and Charlson–Deyo comorbidity score—receiving care at an ACP did not lead to improved outcomes over CCPs (p=0.72) Conclusion: In this large retrospective study involving 2,618 patients with primary cutaneous anaplastic large cell lymphoma (PC-ALCL) identified through the National Cancer Database, we found no survival advantages of treatment in academic center programs (ACPs) compared to Community cancer programs (CCPs). After adjusting for key demographic and clinical variables, we found that ACPs manage a more socioeconomically diverse population, with distinct treatment patterns including higher rates of active surveillance and longer time-to-treatment initiation. Despite these key differences, survival outcomes at 2,5 and 10 years were not statistically significant between the two settings. This suggests that CCP can deliver equivalent care compared to that offered at academic settings for this indolent lymphoma subtype.