Social Determinants of Health and Outcomes in Cutaneous T-Cell Lymphoma in the State of Georgia
Authors: Allen Pamela B. , McCook Ashley , Switchenko Jeffrey M. , Ward Kevin , McCullough Lauren 
Published: December 2023

BACKGROUND
Cutaneous T-cell lymphomas (CTCL) are a complex group of diseases requiring multidisciplinary care with heterogenous outcomes depending on stage at diagnosis and other clinical and pathologic features. The state of Georgia is a diverse region with 33% Black patients, and a mix of rural, urban, and suburban areas. Prior large database studies have lacked the relevant stage and treatment related data to determine the relative roles of disease characteristics and social determinants of health (SDoH) on outcomes in CTCL.
MATERIALS & METHODS.
We performed statistical analysis on patients in the Georgia Cancer Registry diagnosed from 2000-2022 with a first or only CTCL primary diagnosis. CTCL was defined by an ICD-0-3 histology code of 9700, 9701, 9702, 9708, 9709, or 9718, and a site of skin primary. Clinical variables included demographics, disease characteristics, and SdoH. We mapped stage at diagnosis at 3-levels (localized, regional, and distant), and SdoH derived from census tracts. The primary endpoints were overall survival (OS) and cause-specific survival (CSS). Univariate and multivariable analyses were assessed by Cox proportional hazards models.
RESULTS
A total of 1438 patients were in our study cohort. In the state of Georgia, the demographic breakdown was as follows: Male 745 (51.8%), female 693 (48.2%); Race: White 852 (60.1%), Black 538 (37.9%), Other 28 (2.0%), closely mirroring the state demographics. The most common CTCL diagnosis was mycosis fungoides 713 (49.6%). Other diagnoses included: Sezary syndrome (n=18;1.3%), Mature T-cell lymphoma, NOS (n=98; 6.8%), Subcutaneous panniculitis-like T-cell lymphoma (n=8; 0.6%), Cutaneous T-cell lymphoma, NOS (n=444; 30.9%), and primary cutaneous CD30+ T-cell lymphoproliferative disorder (n=157; 10.9%). Stage was localized in 845 patients (58.8%), locally advanced in 140 (9.7%), advanced in 150 (10.4%), and missing in 303 (21.1%). Most patients had private or public insurance, 51 (4.7%) had no insurance.
Patient factors associated with inferior OS and CSS included advanced age at diagnosis (CSS, HR 1.03 (95% CI1.03-1.04), p &lt;.001) and higher stage (CSS, Locally advanced HR 4.46 (3.05-6.54), p&lt;.001, Distant HR 6.94 (4.93-9.76) p &lt;.001 vs. Localized). Receipt of chemotherapy, radiation therapy, or immunotherapy (p &lt; 0.001) were all associated with inferior OS and CSS. Lower income and % &lt; poverty were associated with inferior OS but not CSS.
Several SoDH were associated with inferior OS and CSS . Less insurance coverage was associated with inferior survival (No insurance HR 2.24 (1.24-4.06), p=0.008, and public insurance HR 1.99 (1.46-2.73), p &lt;001 vs. private insurance). Higher Poverty and lower income were also associated with inferior outcomes. Other social determinants including insurance, % with public assistance, management occupations, % unemployed, % owner occupied, and education did not reach statistical significance. On multivariable analysis, age, stage, and receipt of chemotherapy remained significant for CSS and OS, while sex, insurance, and % &lt; poverty level were significant for OS but not CSS.
CONCLUSION
In the state of Georgia, advanced stage, receipt of chemotherapy, and lack of insurance were the most important factors determining poorer cause-specific survival among patients with CTCL. Many patients had unclassified CTCL types (37.7%) and missing stage (21.1%), signifying a need for improved diagnostic and staging algorithms in this disease.