Facility-level variation in hepatosplenic T-cell lymphoma care: Comparative outcomes from academic and community cancer centers

Abstract Background Hepatosplenic T-cell lymphoma (HSTCL) is a rare, aggressive peripheral T-cell lymphoma subtype with poor outcomes and limited standard treatment [Transplantation and Cellular Therapy PMID: 38431075, World Journal of Surgical Oncology PMID: PMID: 39696449] Due to its rarity, disparities in survival and treatment access based on facility type remain poorly described. This study utilizes the National Cancer Database (NCDB) to compare demographic, treatment, and survival outcomes in patients treated at Academic Cancer Programs (ACPs) versus Community Cancer Programs (CCPs).Methods We performed a retrospective analysis of patients diagnosed with HSTCL in the United States between 2004 and 2022 using the NCDB. Demographic, clinical, and outcome data were compared between patients treated at ACPs and CCPs. ACPs included academic and research programs, including NCI-designated comprehensive cancer centers. CCPs comprised community, comprehensive community, and integrated network cancer programs. Kaplan-Meier and Cox proportional hazards models were used to compare overall survival (OS), adjusting for age, race/ethnicity, insurance status, comorbidity score (Charlson-Deyo), and distance from treating facility.Results A total of 518 patients with HSTCL were identified, with 265 (51%) treated at ACPs and 89 (17%) at CCPs; facility type was not available for 164 (31.6%) patients. ACPs cared for a younger population compared to CCPs, with a median age of 56 years vs. 63, and a greater proportion of people younger than 60 years of age (60% vs. 42%, p<0.001). Race distribution showed that the two most affected races across facilities were white (65%) and black (28%), with a higher proportion of white patients being cared for at CCP (75% vs. 65%), and black patients at ACPs (28% vs. 18%). However, the difference was not statistically significant (p= 0.2). Stage IV disease was prevalent in both groups but more common in ACPs (77% vs. 69%). Patients treated at CCPs were more likely to be Medicare-insured (48% vs. 29%, p<0.001), whereas patients treated at ACPs were more likely to have private insurance (52% vs. 35%, p<0.001). Treatment was more often administered at ACPs (76% vs. 64%, p = 0.005). The median time to chemotherapy was similar across facilities (20 days in ACPs and 18 days in CCPs, p = 0.52). Survival analysis showed poor adjusted median OS in both settings: 0.91 years for ACPs and 0.73 years for CCPs. KM survival estimates at 2, 5, and 10 years remained under 25% for both groups. While not statistically significant, trends favored slightly better OS in ACPs. At 2 years, survival was 31% for ACPs vs. 24% for CCPs. At 10 years, OS was 11% and 17%, respectively (p>0.3). Notably, 30-day mortality was higher in CCPs (5.6% vs. 0.4%, p = 0.012).Conclusion HSTCL carries a dismal prognosis across all facility types, with a modest survival advantage observed in patients treated at academic centers. While the rarity of HSTCL limits statistical power, trends suggest earlier diagnosis, better access to therapy, and reduced early mortality in ACPs. These findings underscore the importance of timely referral to specialized centers and ongoing efforts to develop optimal therapeutic strategies for this aggressive lymphoma.