title: Treatment selection and outcomes in early-stage classical Hodgkin lymphoma: analysis of the National Cancer Data Base.
abstract: OBJECTIVE
  The choice between combined-modality therapy (CMT) and chemotherapy alone for early-stage Hodgkin lymphoma (HL) remains controversial. Our objective was to define factors affecting treatment selection and resulting survival outcomes in the United States.
  
  
  METHODS
  We identified 20,600 patients treated with CMT or chemotherapy between 2003 and 2011 from the National Cancer Data Base. Factors affecting treatment selection were studied in a mixed-effects logistic model. Survival outcomes were compared using a propensity score analysis to account for indication bias.
  
  
  RESULTS
  Only 49.5% of patients received CMT, and this proportion steadily declined between 2003 (59.4%) and 2011 (45.2%), particularly in younger patients. Apart from classical prognostic factors (age, stage, tumor location, histology, comorbidities), treatment selection was significantly influenced by sex, black race, distance to facility, and type of insurance. Uninsured patients had the lowest odds of receiving CMT. A significant random effect related to facility-specific treatment preference was also evident. Estimated 5-year overall survival (OS) was 89.6%, and relative survival (RS) was 94.3%. After adjustment for guarantee-time and indication biases, CMT was associated with better OS (hazard ratio [HR], 0.61; 95% CI, 0.53 to 0.70) and RS (excess HR, 0.42; 95% CI, 0.33 to 0.54) than chemotherapy alone. This effect was without significant heterogeneity in subset analysis and was not sensitive to unobserved confounding.
  
  
  CONCLUSIONS
  Socioeconomic factors affect selection of curative treatments in HL. Widespread abandonment of CMT beyond circumstances sanctioned by guidelines may affect survival. Further research should focus on developing strategies that minimize toxicity and access disparities without compromising survival.
authors.affiliation: Adam J. Olszewski and Rajesh Shrestha, Alpert Medical School of Brown University, Providence; Adam J. Olszewski and Rajesh Shrestha, Memorial Hospital of Rhode Island, Pawtucket, RI; and Jorge J. Castillo, Dana-Farber Cancer Institute-Harvard Medical School, Boston, MA. adam.olszewski@brown.edu.
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Olszewski
authors.affiliation: Adam J. Olszewski and Rajesh Shrestha, Alpert Medical School of Brown University, Providence; Adam J. Olszewski and Rajesh Shrestha, Memorial Hospital of Rhode Island, Pawtucket, RI; and Jorge J. Castillo, Dana-Farber Cancer Institute-Harvard Medical School, Boston, MA.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Shrestha
authors.affiliation: Adam J. Olszewski and Rajesh Shrestha, Alpert Medical School of Brown University, Providence; Adam J. Olszewski and Rajesh Shrestha, Memorial Hospital of Rhode Island, Pawtucket, RI; and Jorge J. Castillo, Dana-Farber Cancer Institute-Harvard Medical School, Boston, MA.
authors.forename: Jorge J
authors.initials: JJ
authors.lastname: Castillo
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D006689:Hodgkin Disease / Q000453:epidemiology / Q000473:pathology / Q000628:therapy*; D006801:Humans; D016015:Logistic Models; D008875:Middle Aged; D009367:Neoplasm Staging; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D055815:Young Adult