Breaking Barriers in Classic Hodgkin Lymphoma: Unraveling Disparities between Hispanic and Non-Hispanic Patients Via the National Cancer Database (NCDB)
Authors: Urueta Portillo Daniela , Kaur Supreet , Liu Qianqian , Michalek Joel , Diaz Duque Adolfo Enrique 
Published: December 2023

BACKGROUND
Reducing health disparities in an increasingly diverse population with growing inequality is of paramount importance. Classic Hodgkin lymphoma (cHL), exhibits incidence variations related to socio-environmental factors, socioeconomic status, and migration (PMID 22241896). This research focuses on investigating the disparities between Hispanic (HI) and non-Hispanic (NH) patients diagnosed with cHL; utilizing an extensive dataset, this study represents the largest and most comprehensive effort to date in shedding light on the factors contributing to disparities in cHL incidence and outcomes between these two population groups. The findings from this groundbreaking study can play a crucial role in shaping healthcare policies and practices that foster inclusivity and provide equitable access to quality care, ultimately contributing to the overall health and well-being of the entire nation.
METHODS
Data were analyzed on cHL patients in the US reported to the National Cancer Database (NCDB) between 2004 and 2019. Demographic and treatment characteristics were compared between ethnic groups. Kaplan-Meier and Cox regression analyses were used to compare OS between HI and NH populations. Multivariate analysis and propensity score matching was performed with adjustment for age, stage, co-morbidity score, and insurance status, type of facility and great circle distance.
RESULTS
Out of 84,923 cHL patients, 9% were HI, and 86% NH. 56% of HI were male, compared to 54% of NH . As compared to NH at diagnosis, HI patients were younger (mean 38 years vs. 41 years) (p=&lt;0.001); the majority of HI (84%) and NH (81%) were diagnosed under 65 years of age.
Regarding race, most of HI and NH were White (88% vs 82%), followed by Black (2% vs 13%). When examining the stage, most of HI (33%) and NH (39%) were stage II.
When examining insurance type, private insurance was the most prevalent type in HI vs NH (43% vs 60%), followed by government-sponsored insurance (39% vs 32%). The non-insured group was higher in HI (15%) vs NH (6%) (p=&lt;0.001).
Regarding Census Median Income (2008-2012), the most prevalent bracket for HI was $48,000 - $62,999 (28%), and for NH it was ‘$63,000+‘ (36%). When looking at median income of less than $38,000, HI were 26% vs NH 15%.
Regarding Charlson-Deyo Score (comorbidities score), HI had 7% with a score of =/&gt; 2 score, vs NH 5%. Academic/Research Programs were the most prevalent type of facility providing care for HI (44%) and NH (34%).
Concerning the timing of treatment initiation, NH patients started receiving treatment earlier than HI, with median times of 22 days and 21 days for general treatment and 28 days and 27 days for chemotherapy, respectively (p&lt;0.001).
In contrast, the initiation of immunotherapy showed no significant difference between groups (median: 41 days for HI, 39 days for NH; p=0.762). Radiation therapy was initiated later among HI patients (median: 180 days) compared to NH patients (median: 166 days) (p&lt;0.001).
Mortality rates at 30 and 90 days were higher in the HI population at 1% and 4%, respectively, compared to 1% and 3% in NH population.
On survival analysis; the survival probability at 2, 5 and 10 years of HI vs NH were (86% vs 87%), (82% vs 81%), and (74% vs 73%), respectively. There was not overall survival (OS) difference favoring HI/NH with (p=0.46)
Independently, on multivariate analysis, NH ethnicity was associated with better OS (HR 0.89, CI 0.83-0.96, p&lt;0.01) and private insurance type was associated with better OS (HR 0.69, CI 0.63-0.76, p&lt;0.01)
Interestingly, the propensity matched analysis did not demonstrate significant MS difference between HI vs NH (median 12.9 vs. 13.1 years).
CONCLUSION
Our evaluation of the NCDB did not demonstrate significant disparities in OS outcomes between HI and NH patients diagnosed with cHL. Despite being younger at diagnosis, HI patients exhibited lower access to insurance coverage. Additionally, treatment initiation and clinical outcomes varied among these groups, with HI individuals experiencing higher mortality rates at 30 and 90 days. These insights underscore the urgency to address and rectify the short term pervasive ethnic, socioeconomic, and healthcare inequalities present in the management of cHL. Our findings illuminate the necessity to emphasize the importance of personalizing healthcare strategies to accommodate these socio-cultural nuances, thereby fostering improved and equitable patient outcomes.