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Non-Hodgkins lymphoma: How well you do may depend on where you live

McKay et al.’s study on non-Hodgkin Lymphoma [1] (NHL) in Scotland provides evidence for a graded effect of socioeconomic deprivation on survival and symptoms. Despite an overall improvement in outcomes over the 1979–1996 period, NHL patients from the most deprived areas continued to experience worse results. They found that individuals from the most deprived and moderate areas were at greater risk of death than individuals from the most affluent areas. Scottish patients from more deprived areas were more likely to have B symptoms and poorer performance status levels. These findings suggest that either the disease is more aggressive, or conversely that immune systems of patients in less affluent areas are more compromised. This is a nuance that is absent in the work on NHL coming out of the United States, which largely focuses on differences in incidence rates. McKay et al. speculate that the source of socioeconomic differences in NHL outcomes may lie in differences in either immunocompetence or comorbidity. On the basis of what we know about social determinants of health, both of these are plausible mechanisms. Cozen has enumerated the role of immune factors, particularly those with childhood etiologies, that affect NHL risk [2,3]. The effects of chronic stress on the immune system, which is strongly associated with low socioeconomic status, have been documented in tumor growth and cancer progression in animal and human studies [4]. Similarly, individuals with lower socioeconomic position have increased inflammatory markers and higher prevalence of cardiovascular disease [5,6]. These factors may explain the poorer outcomes among the most deprived patients with NHL. The Scottish investigators used Carstairs scores as a measure of social deprivation, which provide seven deprivation categories (DepCat). These scores are derived from four census variables; car ownership, male unemployment, overcrowding and proportion of males living in social classes IV and V. Note that these variables only depict the average individual in the postal code being studied. By mapping NHL incidence to specific geographic areas, differences in population outcomes may reflect common environmental risk factors that influence the likelihood of death from NHL. These findings are consistent with area based studies on overall cancer mortality in the United States, which show both an increased incidence and higher mortality for major cancer sites among residents of lower income census tracts and block groups [7]. Along these lines a study of 1321 cases of NHL in several American based registries – Seattle, Detroit, Los Angeles and Iowa – examined the risk of NHL [2]. It analysed the effect of a wide range of childhood exposures, atopy, overcrowding, family structure and birth order. It found that the presence of a childhood allergy was associated with decreased risk of NHL and that youngest children from large families were at greater risk for NHL. Immune deficiency, atopic conditions and autoimmune disease may be responsible for differences in NHL incidence [3]. Research on NHL outcomes based on geocoded data are invaluable for further addressing altered immunity or specific