Social determinants linked to inferior survival outcomes for patients with mesothelioma
Click Here to Manage Email Alerts
Key takeaways:
- Patients who underwent curative surgery had median OS of 2.2 years vs. 1.3 years with chemotherapy only.
- Factors linked to poorer OS included male sex, Black race, and lower income and educational attainment.
Social determinants of health and lack of access to specialty cancer care led to survival disparities among patients with malignant pleural mesothelioma, results of a retrospective study showed.
The findings, published in JAMA Network Open, revealed a significant association between curative-intent surgery and longer OS. However, social determinants of health — including race, sex, income and educational attainment — had a negative impact on survival outcomes, the investigators noted.
“Social determinants of health can really explain some of these disparities in outcomes,” Estelamari Rodriguez, MD, MPH, thoracic clinical research lead and associate director for community outreach at Sylvester Comprehensive Cancer Center at University of Miami Miller School of Medicine, told Healio. “There is no clear link between ethnicity, socioeconomic status and the risk for mesothelioma, but many things about living in marginalized communities with limited access to high-level care can explain these differences.”
Background
Malignant pleural mesothelioma is a rarely diagnosed tumor type that has poor OS outcomes despite the availability of multimodal therapy, according to Rodriguez.
“There is an unequal distribution of providers that specialize in treatment of this disease, which can lead to disparities in access and survival,” she said. “The goal of this study was to examine factors associated with patterns of care and identify areas of intervention.”
Methodology
Rodriguez and colleagues conducted an observational retrospective cohort study to determine any association of OS disparities with social determinants of health and treatment access among individuals with operable malignant pleural mesothelioma.
The analysis included 1,389 patients (median age, 66 years; interquartile range, 61-70; 74% male; 89% white; 5% Hispanic; 3% Black) diagnosed with potentially resectable clinical stage I to stage IIIA disease between Jan. 1, 2004, and Dec. 31, 2017, who underwent previous chemotherapy.
Researchers divided the study cohort into two groups — those who received chemotherapy only vs. those who received chemotherapy plus curative surgery.
OS served as the study’s primary endpoint.
Key findings
Results showed median OS of 1.7 years (95% CI, 1.6-1.8) for the entire study cohort.
Patients who underwent curative surgery had median OS of 2.2 years (95% CI, 2-2.4) compared with 1.3 years (95% CI, 1.2-1.5) for those who received chemotherapy only.
Researchers identified Black race as the risk factor most strongly associated with poorer OS outcomes (HR = 1.96; 95% CI, 1.43-2.69), followed by male sex (HR = 1.6; 95% CI, 1.38-1.86).
Other factors linked to poorer OS included lower income (HR = 1.19; 95%CI, 1.06-1.34) and lower educational attainment (HR = 1.21; 95% CI, 1.06-1.37).
Investigators identified receiving surgery in addition to chemotherapy as independently associated with improved OS (HR = 0.7; 95% CI, 0.61-0.8).
Further adjusted analyses showed independent associations of decreased travel distance (HR = 0.92; 95%CI, 0.86-0.98) and treatment at nonacademic centers (HR = 1.18; 95%CI, 1.01-1.37) with worse OS.
“Surgery for malignant pleural mesothelioma is complex and may not be offered at centers close to patients’ homes because they require highly specialized tertiary centers,” Rodriguez told Healio. “We found that surgeries at centers greater than 250 miles [from patients’ residences] were associated with greater survival probability compared with surgery [centers] less than 250 miles or no surgery, which meant that patients who had the financial means to travel farther for surgery and had surgery at tertiary academic centers had better outcomes.”
Those who received curative surgical treatment as part of a multimodal therapy approach had a 30% increased likelihood of survival compared with those who received chemotherapy alone (HR = 0.7; 95% CI, 0.61-0.8).
Clinical implications
The results suggest that social determinants of health — most notably, race, access to transportation and income — play an important role in survival outcomes among patients with malignant pleural mesothelioma, according to Rodriguez.
“Although Black patients comprised only 5% of those treated [during the study] period, race disparities were evident because Black patients were 80% more likely to die than white patients,” she told Healio.
Future studies should focus on whether increasing access to early diagnosis and high-quality multimodality care can improve OS among different ethnic groups or whether other environmental or genetic factors have a larger impact on outcomes, Rodriguez said.
Additionally, because it remains the main cause of the disease, analyses looking at the legacy effects of asbestos use among immigrant communities would be of interest, she added.
“This study demonstrates that patients with malignant pleural mesothelioma can benefit from surgery and early, multimodal treatment, but the resources in the United States are not equally distributed,” Rodriguez said. “Improving access to specialized multimodality care [for those with] malignant pleural mesothelioma is a priority, not only because it is the ethical thing to do, but because it will improve survival outcomes for this difficult disease.”
For more information:
Estelamari Rodriguez, MD, MPH, can be reached at Division of Medical Oncology, Department of Internal Medicine, University of Miami Miller School of Medicine, 1475 NW 12th Ave., Miami, FL 33136; email: estelarodriguez@miami.edu.
Collapse
Read more about
Click Here to Manage Email Alerts