Background

Follicular lymphoma (FL) is the second most common non-Hodgkin lymphoma in the United States and Europe. While most patients experience an indolent disease course, a subset of patients present with aggressive disease, early relapses, and overall poor outcomes. Given its clinical heterogeneity, there are varied treatment approaches and outcomes across different healthcare settings [J Clin Oncol PMID: 26124482, Am J Hematol PMID: 36255040]. While prior studies have examined sociodemographic disparities in hematologic malignancies [BloodAdvances PMID: 38607394], limited data exist comparing survival outcomes for patients with FL treated at Academic Cancer Programs (ACPs) versus Community Cancer Programs (CCPs). This study utilizes the National Cancer Database (NCDB) to assess clinical, demographic, and survival differences across these facility types.Methods

We conducted a retrospective analysis of patients diagnosed with FL in the United States between 2004 and 2022 using the National Cancer Database. Demographic, clinical, and survival 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 158,994 patients with follicular lymphoma (FL) were identified, with 79,264 (50%) treated at Academic Cancer Programs (ACPs) and 73,546 (46%) at Community Cancer Programs (CCPs); facility type was unavailable for 6,184 patients (4%). CCP-treated patients were older (median age, 67 vs. 65 years, p < 0.001), with a greater proportion aged ≥75 years (28% vs. 23%), whereas ACPs cared for more patients under 60 (35% vs. 30%).

Race/ethnicity distribution showed that ACPs treated slightly more Black (6% vs. 4%) and Hispanic (7% vs. 5%) patients (p<0.001). Income and education levels were lower in CCP-treated populations, with ACPs managing more patients in census tracts where fewer than 14% of adults lacked a high school diploma (38% vs. 32%, p<0.001).

Insurance coverage differed significantly: CCPs had a higher proportion of Medicare patients (53% vs. 46%), whereas ACPs had higher rates of private insurance (43% vs. 39%). Medicaid-insured patients (5% vs. 4%) and uninsured patients (2% vs. 2%) were also slightly more numerous in ACPs.

Regarding treatment approaches, ACPs were more likely to manage patients with active surveillance (12% vs. 9%, p<0.001), while CCPs performed slightly more radiation therapy (14% vs. 13%, p<0.001). Time to chemotherapy was shorter at CCPs (median 34 vs. 36 days, p<0.001).

Survival analysis revealed a longer adjusted median overall survival for ACP patients (13.95 vs. 12.68 years, p < 0.001). Kaplan–Meier–estimated OS at 2, 5, and 10 years favored ACPs: 88%, 77%, and 61%, respectively, compared to 87%, 75%, and 58% for CCPs. In a multivariable Cox model—adjusting for age, race/ethnicity, insurance status, great-circle distance to care, and Charlson–Deyo comorbidity score—receiving care at an ACP remained independently associated with improved OS (HR <1.0, p<0.01).Conclusion

In this large, nationally representative cohort of over 158,000 patients with FL, treatment at ACPs was independently associated with significantly improved long-term survival CCPs. Patients treated at ACPs had superior 2-, 5-, and 10-year overall survival, despite only modest differences in treatment timelines. These findings remained significant after adjusting for sociodemographic factors, insurance status, comorbidities, and distance to care. The results suggest that access to multidisciplinary expertise, research-driven protocols, and comprehensive supportive care at ACPs may contribute to better outcomes. Addressing these disparities through expanded academic-community partnerships and standardization of care delivery is crucial for improving survival rates for all patients with follicular lymphoma.

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2025
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