Access to care varies greatly among patients with malignant pleural mesothelioma
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Access to care varied significantly among patients with stage I to stage III malignant pleural mesothelioma, according to study results.
The findings — presented at International Association for the Study of Lung Cancer World Conference on Lung Cancer — showed variations in access based on factors such as distance to treatment facility, as well as facility type and volume.
In addition, receipt of chemotherapy or multimodality treatment predicted better outcomes regardless of patients’ race, socioeconomic status and tumor characteristics, Estelamari Rodriguez, MD, medical oncologist at University of Miami Sylvester Comprehensive Cancer Center, and colleagues found.
“Malignant pleural mesothelioma is a disease [for which] timely access to multidisciplinary care can make all the difference in prognosis,” Rodriguez told Healio. “Prior studies have shown that up to 40% of patients with malignant pleural mesothelioma, especially older patients, do not receive any specific modality of treatment. Understanding how social determinants of health and socioeconomic status impact access to care is important to eradicate disparities in malignant pleural mesothelioma.”
Malignant pleural mesothelioma is associated with poor prognosis. Approximately 10% of patients survive 5 years. Those with localized malignant pleural mesothelioma often experience poor outcomes, even if they receive multimodality therapy.
Data assessing the potential association between disparities in care access and patients’ socio-economic status with outcomes for this population are limited, according to study background.
“Understanding how disparities in socioeconomic status and access to care can play a role in prognosis is important in order to optimize outcomes for all patients,” Rodriguez said.
Rodriguez and colleagues examined factors associated with patterns of care and OS among patients with malignant pleural mesothelioma, accounting for treatment access and socioeconomic status.
Researchers used the National Cancer Database to identify 2,804 patients (median age, 65 years; interquartile range, 58-70) with stage I to stage IIIA malignant pleural mesothelioma treated between 2004 and 2017.
Fifty percent of patients (n = 1,402) underwent surgery. Most of these patients were men (70%) and white (83.1%), had stage I or stage II disease (86.7%), had pathologically defined epithelioid mesothelioma (58.9%), and had private insurance (47.7%) or Medicare (44.6%).
Most surgeries took place at academic centers (57.3%), at high-volume facilities and in urban areas.
Patients who underwent surgery traveled a significantly farther distance for treatment (mean, 16.1 miles vs. 14.4 miles; P < .001).
“The majority of patients who had surgery were white, with private/Medicare insurance, and had access to multidisciplinary care in high-volume, academic facilities,” Rodriguez said. “Very few patients who had surgery were uninsured or came from rural areas.”
Researchers performed multivariable analysis to assess the effect of treatment on survival. They controlled for several factors, including age, sex, zip code-level income and education, disease histology and stage, Charlson-Deyo Comorbidity Index score and hospital characteristics.
Researchers reported significantly improved survival among patients who received surgery plus chemotherapy (adjusted HR [aHR] = 0.6; 95% CI, 0.55-0.67) or surgery plus chemotherapy and radiotherapy (aHR = 0.73; 95% CI, 0.62-0.86) compared with those who received chemotherapy alone. Prolonged chemotherapy duration also had a small but statistically significant association with improved OS (aHR = 0.99; 95% CI, 0.997-0.999).
“The findings of this study suggest that patients without access to expert multidisciplinary care at high-volume, academic facilities are being inappropriately undertreated for their disease due to lack of access,” Rodriguez said.
Researchers did not observe a linear relationship between income and survival.
Patients in the third quartile of income ($50,354-$63,332) exhibited a 17% lower risk for mortality than those in the highest quartile (HR = 0.83; 95% CI, 0.74-0.92). However, results showed no significant effect between the two lowest income quartiles (less than $40,227 per year, or $40,227 to $50,353 per year) compared with the highest quartile.
“Although patients with lower income had lower survival than those with higher income, we were surprised that the highest quartile of income — more than $63, 000 — had lower survival than the middle quartile, which was not previously reported,” Rodriguez said.
Multivariable analysis showed no difference in OS by race, neighborhood socioeconomic status, insurance status, education, comorbidity index, or facility type or volume.
Significant predictors of shorter OS included advanced age (adjusted HR = 1.02; 95% CI, 1.02-1.03) and male sex (adjusted HR = 1.43; 95% CI, 1.29-1.58).
“Understanding what other social determinants of health — such as transportation, housing segregation, education, occupational exposure and physician bias — may impact survival in mesothelioma needs to be explored further,” Rodriguez said.
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Rodriguez E, et al. Abstract OA13.02. Presented at: International Association for the Study of Lung Cancer World Conference on Lung Cancer (virtual meeting); Sept. 8-14, 2021.
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