Treatment Outcomes for Patients with Hodgkin's Lymphoma at a Safety Net Hospital
Authors: Yashar David , Tomassetti Sarah , Marshalek Joseph , Chao Eugene , La Barbera Katie , Amaya Andy 
Published: December 2024

Background:
Outcomes for patients with Hodgkin's lymphoma (cHL) have improved over the past decade given the use of agents such as Brentuximab vedotin (BV) and anti-PD-1 agents. Unfortunately, there are still disparities among minorities such as Hispanics and African Americans. These patients have unique barriers such as lower socio-economic status, lack of access to healthcare and treatment. In addition, these patients have decreased overall survival (OS) compared to caucasian patients. Here we look at treatment outcomes for patients with cHL in a county hospital setting in which the majority are Hispanic and African American.
Methods:
IRB approval was obtained from The Lundquist Institute's John F. Wolf Subcommittee ethics board to collect data from Cerner Millenium's Power Chart for this observational retrospective cohort study on individuals diagnosed with cHL. IBM SPSS v28.0 was used to compute descriptive and analytical statistics. For dates with missing information, January 1st of the listed year was used to ensure dataset consistency. Patients were excluded from analysis if they lacked a known initial treatment date, were still in treatment without a first-line response assessment, or had no first-line response assessed due to being lost to follow-up (LTFU). Progression-free survival (PFS) was assessed in three stages: PFS 1 (time between diagnosis and last contact, with first relapse as the event of interest), PFS 2 (time between first and second relapse), and PFS 3 (time between second and third relapse). OS was measured from the diagnosis date to the date of last contact, with death as the event of interest.
Results:
The study included 89 patients diagnosed with cHL. The mean age at diagnosis was 40.6 years and the cohort consisted of 65.2% males (n=58) and 34.8% females (n=31). Ethnically, 66.3% were Hispanic (n=59), 13.5% African American (n=12), 4.5% Asian (n=4), 10.1% Non-Hispanic White (n=9), 3.4% Other (n=3), and 2.2% Unknown (n=2). Regarding HIV status, 91.0% were negative (n=81) and 9.0% positive (n=8). Additionally, 15.7% of patients that relapsed underwent autologous stem cell transplantation (Auto SCT).
At diagnosis, 4.5% of patients (n=4) were at stage IA, 1.1% (n=1) at stage IB, 10.1% (n=9) at stage IIA, 22.5% (n=20) at stage IIIA, 6.7% (n=6) at stage IIIB, 14.6% (n=13) at stage IV, 14.6% (n=13) at stage IVA, 2.2% (n=2) at stage IVB, and 21.3% (n=19) had staging not recorded. For first-line treatment, 75.3% of patients (n=67) achieved a complete response (CR), 5.6% (n=5) had a partial response (PR), 3.4% (n=3) had stable disease (SD), 10.1% (n=9) experienced progressive disease (PD), and 5.6% (n=5) were not evaluated (NE).
The first-line therapies included ABVD for 61.8% of patients (n=55), AVD for 2.2% (n=2), ABVD switched to AVD for adverse event resolution in 4.5% (n=4), ABVD or AVD plus radiotherapy (RT) in 6.7% (n=6), RT alone in 2.2% (n=2), BEACOPP or EACOPP in 4.5% (n=4), BV plus VD or AVD in 9.0% (n=8), other therapies in 6.7% (n=6), and not recorded or not given in 2.2% (n=2).
For second-line therapy, 39.1% of patients (n=9) received ICE, 8.7% (n=2) ABVD, 8.7% (n=2) GEMOX, 4.3% (n=1) IGEV, 4.3% (n=1) Brentuximab, 13.0% (n=3) Nivo plus ICE or BV, 4.3% (n=1) BV-ICE, and 8.7% (n=2) other or unknown therapies. Third-line therapies included Brentuximab for 44.5% of patients (n=4), BV for 11.1% (n=1), DHAP for 11.1% (n=1), GEMOX for 11.1% (n=1), Nivo-ICE for 11.1% (n=1), and Ritux plus Vinc plus Cytoxan for 11.1% (n=1). Fourth-line therapies were ABVD for 25% of patients (n=1), Nivolumab for 25% (n=1), and Pembrolizumab for 50% (n=2). The PFS 1,PFS 2, and PFS 3 was 161, 103, and 76 months, respectively. OS was assessed with a mean survival time of 212 months.
Conclusion:
In conclusion, this study showed an overall survival of around 212 months or about 17.6 years, which is below the reported median OS of 33 years in patients with cHL. We also see the use of ABVD in the first line setting for the majority of patients, and no use of BV. Only 15.7% of patients who relapsed received transplant. There was also low usage of nivolumab overall in our patient population in the relapsed/refractory setting. The reason for decreased OS can be attributed to resource limitations, poor socio-economic status, and lack of access to transplantation among other factors. This study helps to delineate some factors for worse outcomes among minorities who have cHL, and more work needs to to help improve outcomes for these patients.