Survival Disparities in Patients With Lymphoma According to Place of Residence and Treatment Provider: A Population-Based Study

Abstract

A B S T R A C T PurposeHealth disparities exist according to an individual's place of residence. We evaluated the association between primary area of residence (urban v rural) according to treatment provider (university based v community based) and overall survival in patients with lymphoma and determined whether there are patient groups that could benefit from better coordination of care. Patients and MethodsPopulation-based, retrospective cohort study of 2,330 patients with centrally confirmed lymphoma from Nebraska and surrounding states and treated by university-based or community-based oncologists from 1982 to 2006. ResultsAmong urban residents, 321 (14%) were treated by university-based providers (UUB) and 816 (35%) were treated by community-based providers (UCB). Among rural residents, 332 (14%) were treated by university-based providers (RUB), and 861 (37%) were treated by community-based providers (RCB). The relative risk (RR) of death among UUB, UCB, and RUB were not statistically different. However, RCB had a higher risk of death (RR, 1.37; 95% CI, 1.14 to 1.65; P ϭ .01; and RR, 1.26; 95% CI, 1.06 to 1.49; P ϭ .01) when compared with UUB and RUB, respectively. This association was true in both low-and intermediate-risk patients. Among high-risk patients, UCB, RUB, and RCB were all at higher risk of death when compared with UUB. ConclusionSurvival outcomes of patients with lymphoma may be associated with place of residence and treatment provider. High-risk patients from rural areas may benefit from better coordination of care.

Hematologist/oncologist disease‐specific expertise and survival: Lessons from chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL)

“…Consistent with previous reports 2,25 and potentially due to referral bias, survival of patients cared for at Mayo Clinic was longer than patients in the SEER registry(n=1087) diagnosed with CLL 1999–2004(Figure 3A). For all patients (January 1999 – September 2009), median OS of patients cared for by a CLL hematologist(directly or with fellow) was 10.5 years as compared to 8.4 years(p=0.001) for those cared for by a non-CLL hematologist(directly or with fellow).…”

“…rural versus metropolitan area; community based versus university-based) may influence survival. 25 While these observations could be due to greater disease-specific expertise among physicians at university and large metropolitan centers, they may simply reflect referral bias or better access to advanced technologies, clinical trials, supportive care, and multidisciplinary support at large centers. Little is known about the direct influence of the hematologist/oncologist’s disease-specific expertise on the outcome of patients cared for in the same practice setting where access to clinical trials, multidisciplinary consultation, and medical technologies are identical.…”

Effect of Place of Residence and Treatment on Survival Outcomes in Patients With Diffuse Large B-Cell Lymphoma in British Columbia

“…In the Canadian province of Manitoba, where a similar provincewide cancer control program is in place, a population-based study of all patients undergoing bone marrow transplantation for lymphoma failed to show a survival disadvantage for rural patients [23]. In a population-based, retrospective cohort of 2,330 patients with lymphoma from the U.S. state of Nebraska, patients from rural areas had inferior OS compared with those residing in urban areas [12]. In addition, rural patients treated in Nebraska were less likely to receive SCT as part of their treatment [13,24].…”

“…Limited data suggest that rural patients with different lymphoma subtypes may experience adverse outcomes [12][13][14]. Patients with curable aggressive lymphomas, such as diffuse large B-cell lymphoma (DLBCL), could be particularly vulnerable to the effect of place of residence because timely administration of therapy at appropriate dose intensity is considered vital for optimizing outcome.…”

Does location matter? Rural vs urban outcomes after blood and marrow transplantation in a population-based Canadian cohort

“…One study 5 showed that American patients treated by university-based providers were significantly more likely to have a BMT as part of their treatment regimen as compared with patients treated by community-based providers, but did not find a difference between patients from rural and urban areas overall . We investigated this issue in rural and urban Canadians.…”