Rural-urban disparities in survival rates in adult Hodgkin lymphoma: A population-based study

Abstract Introduction Hodgkin's lymphoma is known to have favorable survival outcomes; however, limited data exist regarding survival disparities between rural and urban populations. In this study, we aimed to investigate the differences in survival outcomes between the two populations. Methods Data for patients diagnosed with Hodgkin lymphoma (HL) between 2000 and 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Rurality was identified using the Rural-Urban Continuum Codes (RUCC). Patients aged ≥ 20 years with HL as the only primary malignancy were included. Individuals with unknown race or those diagnosed at autopsy were excluded. The Ann Arbor Staging system was utilized for HL staging at diagnosis. HL-specific survival was defined as the time from diagnosis to death attributable to HL and was censored at the time of death from other causes or at last follow-up. Meanwhile, overall survival (OS) was defined as the time from diagnosis to death from any cause and was censored if the patient was still alive. A Cox proportional hazards model was performed to analyze the predictors for 10-year overall and HL-specific mortality. All statistical analyses were conducted using RStudio (version 2024.12.0). Results Between 2000 and 2015, a total of 22,505 patients diagnosed with Hodgkin lymphoma (HL) were included in the analysis. Among them, 13,657 (61%) were aged between 20 and 44 years. Overall, 10,137 patients (47%) were female, 14,885 (66%) were White, 2,672 (12%) were Black, and 3,724 (17%) were Hispanic. The majority of patients resided in urban counties, while only 2,266 (10.1%) lived in rural areas. Among rural patients, 845 (37%) were diagnosed with stage II disease, followed by 475 (21%) with stage III at the time of diagnosis. Notably, both the 10-year overall survival (69.5%) and Hodgkin lymphoma–specific survival (79.7%) were significantly lower among rural patients compared with urban patients (75.3% and 83.5%, respectively; p < 0.001). In the multivariable model for 10-year HL-specific survival, older age (> 65 years) was associated with the highest risk of mortality (HR 10.32; 95% CI 9.42–11.32). Although survival improved over the study period, male patients remained at increased risk of mortality (HR 1.26; 95% CI 1.18–1.35). Urban residence, diagnosis in more recent years, early stage, female sex, White race, and married status were independently associated with improved overall survival (p < 0.01). Conclusion In this population-based study, both the 10-year overall and HL-specific survival were consistently lower among rural vs. urban patients. Male sex, older age, and unmarried status were particularly associated with worse survival outcomes. Further research is warranted to identify possible strategies for improving healthcare access and reducing survival disparities among rural patients.