Continuous tobacco smoking increases mortality in diffuse large B-cell lymphoma but not follicular lymphoma, a Finnish population-based study

Taina Reunamo; Erika Alanne; Toni Mikkola; Antti Karlsson; Antti Ellonen; Tarja Laitinen; Maarit Bärlund; Pia Österlund; Heikki Minn; Sirpa Leppä; Sirkku Jyrkkiö; Eetu Heervä

doi:10.2340/1651-226X.2025.44776

Authors

Taina Reunamo Turku University Hospital and University of Turku, Department of Oncology, Turku, Finland; Wellbeing services county of Southwest Finland, Turku, Finland https://orcid.org/0009-0005-1675-1436
Erika Alanne Turku University Hospital and University of Turku, Department of Oncology, Turku, Finland; Wellbeing services county of Southwest Finland, Turku, Finland; Western Finland Cancer Centre, Turku, Finland https://orcid.org/0000-0003-1925-0192
Toni Mikkola Department of Oncology and Tays Cancer Center, Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland https://orcid.org/0009-0009-6706-4053
Antti Karlsson University of Turku, Turku, Finland; Pihlajalinna Oyj, Tampere, Finland https://orcid.org/0000-0003-1556-3351
Antti Ellonen Turku University Hospital and University of Turku, Department of Oncology, Turku, Finland; Wellbeing services county of Southwest Finland, Turku, Finland https://orcid.org/0000-0001-5902-6182
Tarja Laitinen Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland https://orcid.org/0009-0003-7062-8629
Maarit Bärlund Department of Oncology and Tays Cancer Center, Tampere University Hospital, Wellbeing; Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland https://orcid.org/0000-0002-1469-5654
Pia Österlund Department of Oncology and Tays Cancer Center, Tampere University Hospital, Wellbeing; Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland https://orcid.org/0000-0002-7124-3515
Heikki Minn University of Turku, Turku, Finland https://orcid.org/0000-0002-5878-4333
Sirpa Leppä University of Helsinki, Faculty of Medicine, Department of Oncology and Research Programs Unit, Helsinki, Finland; Helsinki University Hospital Comprehensive Cancer Centre, Helsinki, Finland https://orcid.org/0000-0002-8265-511X
Sirkku Jyrkkiö Turku University Hospital and University of Turku, Department of Oncology, Turku, Finland; Wellbeing services county of Southwest Finland, Turku, Finland https://orcid.org/0000-0001-6826-9354
Eetu Heervä Turku University Hospital and University of Turku, Department of Oncology, Turku, Finland https://orcid.org/0000-0002-6134-1170

DOI:

https://doi.org/10.2340/1651-226X.2025.44776

Keywords:

Tobacco smoking, diffuse large B-cell lymphoma, follicular lymphoma, real word data

Abstract

Background and purpose: Tobacco smoking was prognostic in B-cell lymphomas in the pre-rituximab era, but the association with modern treatment, stage, subtypes, and survival outcomes remains unclear.

Patient/material and methods: All patients with diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL) from Turku and Tampere University Hospitals 2009–2019 were identified. Population-based data from electronic medical records included demographics, tumour histology, Ann Arbor staging, and treatments. Smoking status was extracted with a deep learning-based natural language processing algorithm. Kaplan–Meier overall survival (OS) estimates and adjusted hazard ratios (HRs) were calculated.

Results: With a median follow-up of 96 months, 1,258 patients with DLBCL and 529 with FL were included. In DLBCL, the 5-year OS rate was 61%, 53%, and 45% among never, former, and persistent smokers, respectively. Persistent smoking remained an independent prognostic factor for shorter OS, HR 1.27 (95% confidence interval 1.10–1.60) after adjustment for comorbidities and completed treatment. The prognosis of FL was indolent with no difference in OS regardless of smoking status, with 5-year OS rates of 79%, 75%, and 74% among never, former, and persistent smokers, respectively. Smokers were younger at diagnosis, while other baseline demographics were similar. No differences in the systemic therapy use were observed between the different smoking categories in both FL and DLBCL.

Interpretation: Overall and lymphoma-specific mortality is increased in persistent smokers with DLBCL compared with never smokers. Smoking prevention and cessation support remains of utmost importance.

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Continuous tobacco smoking increases mortality in diffuse large B-cell lymphoma but not follicular lymphoma, a Finnish population-based study

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Continuous tobacco smoking increases mortality in diffuse large B-cell lymphoma but not follicular lymphoma, a Finnish population-based study

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