Evaluation of the effect of care at NCI comprehensive cancer centers on disparities in outcome within adolescents and young adults with cancer

Reporter: J. Taylor Whaley, MD
The Abramson Cancer Center of the University of Pennsylvania
Ultima Vez Modificado: 4 de junio del 2012

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Presenter: Dr. Can-Lan Sun, PhD on behalf of Julie Anna Wolfson, M.D.
Presenter's Affiliation: City of Hope, Duarte, CA

Background

  • The National Cancer Institute defines adolescents and young adults (AYAs) with cancer as individuals aged 15-39 years of age at the time of diagnosis with cancer. Despite sharing similar diagnoses, this particular collection of patients has not seen the survival improvement that has been demonstrated by younger and older age groups.
  • This disparity is known as the AYA Gap.
  • While treatment on pediatric protocols is associated with superior survival in 15-21 year-olds, the impact of site of care on survival for vulnerable AYA subpopulations (age at diagnosis or race/ ethnicity) between 22-and 39y at diagnosis remains unstudied.
  • In the past several decades, children under the age of 18 years of age have demonstrated improvements in survival of approximately 1.5% per year as treatments have evolved. Adults over 39 years old have demonstrated similar improvements. AYAs have not seen this improvement.
  • NCI-designated Comprehensive Cancer Centers (NCICCC) are hospitals that take leadership roles in developing new approaches to treating cancers. They are responsible translating scientific knowledge from new discoveries into potential treatments for cancer patients. Additionally, they are required to meet high standards for both patient care as well as scientific research.
  • The purpose of this study was to address the AYA gap and evaluate survival following cancer diagnoses across the spectrum of diseases by evaluating race, site of cancer treatment, role of NCICCC, impact of NCI on disparities, and proportionality of various races receiving care at NCICCC.

Materials and Methods

  • The authors constructed a patient cohort of 10,727 patients with newly diagnosed cancer between the ages of 22 and 39 years of age with lymphoma, leukemia, brain tumors, sarcomas, melanoma, thyroid and GU cancers, and reported to the LA County cancer registry between 1998 and 2008.
  • Within Los Angeles County, three NCI Comprehensive Cancer Centers operate. These include City of Hope Cancer Center, Jonsson Cancer Center and Norris Cancer Center.
  • The primary outcome evaluated was overall survival.
  • Variables analyzed included race/ethnicity, age at diagnosis, Socioeconomic Status (SES), insurance status, primary cancer diagnosis and diagnosis year in the model.
  • Multivariable Cox regression analysis was conducted, and the analysis was stratified by site of care (NCICCC vs. non-NCICCC).

Results

  • A total of 928 (9%) patients received treatment at the 3 NCICCCs in LA County, and 9,799 (91%) received care elsewhere at non-NCICCC.
  • Baseline characteristics revealed that 44% of patients in the study were white, 40% were of Hispanic race, and 5% were African American.
  • 43% of patients were in the high SES, 19% were in the middle SES, and 36% were in the low SES group. White patients were more likely to be in the high SES group.
  • 69% of all patients had private insurance. Hispanic and AA were more likely to have public or no insurance.
  • Five-year overall survival was significantly worse for patients treated at non-NCICCC (84%) when compared with those treated at NCICCC (87%).
  • In addition, 5 year overall survival was significantly worse for African Americans (71%) vs. non-Hispanic whites (89%) and for older patients in the AYA group, aged 31-39 years old: 84%, vs. 22-30 y/o: 86%. Additionally, although Hispanics did better than African Americans, they too had statistically significant worse outcomes.
  • Multivariable analysis adjusting for SES, insurance status, diagnosis and diagnosis year revealed that African Americans (HR=1.4) and older AYAs (31-39y: HR=1.24) were at a significantly increased risk of death.
  • Among patients treated at NCICCC, the difference in risk of death due to race and age was mitigated.
  • Conversely, among patients treated at non-NCICCC even when adjusting for age, sex, diagnosis, year of diagnosis, and SES, these differences in outcome persisted (African Americans: HR=1.45; 31-39yo: HR=1.25) with African
  • Americans and older patients demonstrating decreased overall survival.
    Finally, patients were most likely to seek care at an NCICCC if they were white, high SES, and privately insured.

Limitations

  • This study was a retrospectively gathered cohort with no specific treatment information available. Because of the inherent limitations of a retrospective study, definitive conclusions are difficult to create.
  • Additionally, it is unclear if the care at the NCICCC was different. There is a possibility that patients at the NCICCC were more likely to be treated on randomized trials, possibly skewing these results.

Author's Conclusions

  • Population-based data reveal that African American and Hispanic AYAs with cancer have significantly worse outcomes than their White counterparts, even when controlling for age, sex, diagnosis, year of treatment, and SES.
  • Additionally, five-year overall survival was significantly worse for AYAs treated at non-NCICCC when compared with those treated at NCICCC.
  • Adjustments for co-variables resulted in mitigation at treatment centers; however, treatment at an NCICCC mitigates the effects of race and older age on mortality in AYAs with cancer more significantly.
  • African American and Hispanic patients are less likely to use NCICCC, independent of insurance status, age, sex and diagnosis. The barriers to accessing care at NCICCCs remain unclear.

Clinical Implications

  • Disparities among adolescents and young adults with cancer are known to exist, with patients aged 15-39 years old demonstrating worse overall survival than both younger and older patients with similar diagnoses.
  • The authors present a provocative study, highlighting this gap in LA County. Certainly additional studies are needed to further evaluate the etiologies of these differences with respect to particularly poor outcomes in minorities and older patients, ages 31-39. Although likely, it remains unknown if these differences exist across the United States and in other countries.
  • It will be very intriguing for future studies to investigate the rationale for barriers to access at NCICCCs for minorities.


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