Use of Combined-Modality Therapy vs Chemotherapy Alone in Early Hodgkin Lymphoma Affected by Sex, Race, Distance to Treatment, and Insurance


Key Points

  • Use of combined-modality therapy declined from 59% to 45% between 2003 and 2011.
  • Factors associated with less use of combined-modality therapy included female sex among young patients, black race, insurance other than private insurance, and greater distance to treatment facility.

In a study reported in the Journal of Clinical Oncology, Olszewski et al found that numerous factors affected use of combined-modality therapy vs chemotherapy alone in early-stage Hodgkin lymphoma, including sex, race, insurance, and distance to treatment facility.

Study Details

The study involved data from the National Cancer Data Base on 20,600 patients treated with combined-modality therapy or chemotherapy between 2003 and 2011. Overall, 10,200 patients (49.5%) received combined-modality therapy, with use decreasing from 59.4% in 2003 to 45.2% in 2011 and the steepest decrease being observed in women aged < 30 years (annual percent change of −4.5%).

Factors Associated With Use

The odds of receiving combined-modality therapy decreased with age; in the youngest group (18–29 years), women were less likely to receive combined-modality therapy than men (odds ratio [OR] = 0.87, P = .0083). Combined-modality therapy was used less frequently in patients with B symptoms, subdiaphragmatic tumors, or lymphocyte-depleted histology. Black patients were significantly less likely to receive combined-modality therapy vs whites (OR = 0.84, P = .0043), even after adjustment for insurance, income, and education. Patients with private insurance were significantly more likely to receive combined-modality therapy compared with those who were uninsured (OR = 0.72, P < .001) or who had Medicaid (OR = 0.86, P = .010) or Medicare (OR = 0.80, P = .0013). Combined-modality therapy was used less frequently in academic centers vs community facilities (OR = 0.81, P = .015), in some geographic regions (ORs = 0.67, P < .001, for Southeast and 0.62, P < .001, for West vs Northeast), and when distance to the treatment facility was ≥ 50 miles (OR = 0.75, P < .001, vs < 50 miles).

A significant random effect related to facility-specific treatment preference was also observed. Of 1,351 treatment facilities, 11% used combined-modality therapy in < 10% of cases, and 6% used combined-modality therapy in > 90% of cases. Facilities treating fewer than seven patients used combined-modality therapy in 42% of cases, whereas those treating more patients used combined-modality therapy in 51% of cases.


Among all patients, estimated 5-year overall survival was 89.6%, and relative survival (compared with expected survival in the general population matched for age, sex, race, and calendar year) was 94.3%. In adjusted analysis, combined-modality therapy was associated with greater overall survival (hazard ratio [HR] = 0.61, 95% confidence interval [CI] = 0.53–0.70) and relative survival (excess HR = 0.42, 95% CI = 0.33–0.54) vs chemotherapy alone.

The investigators concluded: “Socioeconomic factors affect selection of curative treatments in [Hodgkin lymphoma]. Widespread abandonment of [combined-modality therapy] beyond circumstances sanctioned by guidelines may affect survival. Further research should focus on developing strategies that minimize toxicity and access disparities without compromising survival.”

Adam J. Olszewski, MD, of Alpert Medical School of Brown University, is the corresponding author for the Journal of Clinical Oncology article.

Jorge J. Castillo, MD, reported a consulting or advisory role with Otsuka Pharmaceuticals and research funding from Millennium Pharmaceuticals and GlaxoSmithKline.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.