Evaluation of Racial, Ethnic, and Socioeconomic Associations With Treatment and Survival in Uveal Melanoma, 2004-2014

Health disparities in ocular oncology

Social determinants of health (SDH) play a crucial role in shaping health outcomes. Few studies have explored the impact of SDH in ocular oncology, looking at differences in disease presentation, treatment choices, and outcomes based on race, ethnicity, socioeconomic status (SES), and insurance status. Retinoblastoma exhibits disparities in survival, with lower-income countries experiencing substantially lower rates compared to high-income countries. In the U.S., racial and SES disparities exist, impacting treatment choices and outcomes in children with retinoblastoma. Disparities in treatment modalities based on race and SES have been reported in uveal melanoma, with non-White and economically disadvantaged patients more likely to undergo primary enucleation. Ocular surface squamous neoplasia (OSSN) exhibits racial and socioeconomic disparities in treatment outcomes. Black patients with OSSN face higher mortality, independent of tumor size, eye laterality, or tumor behavior. Given the rarity, there is no data on disparities in vitreoretinal lymphoma management. When using primary central nervous system lymphoma as a surrogate, management and survival outcomes vary based on factors such as race, socioeconomic status, and insurance status. This article aims to review current literature on disparities in ocular oncology, highlighting the need for granular data to better understand existing gaps in care within ocular oncology.

Disparities in ovarian cancer survival among ethnic Asian American populations, 2006-2020

BACKGROUND

Asian Americans have the highest ovarian cancer survival across the major racial groups although it is unclear whether this survival advantage is observed when each Asian ethnic subgroup is examined separately. Disaggregated survival analyses of this heterogeneous population is needed to ensure ethnic-specific disparities are not overlooked.

METHODS

Data on ovarian cancer cases diagnosed from 2006 through 2020 from the Surveillance, Epidemiology, and End Results (SEER) Program were analyzed. Age-standardized five-year cause-specific survival was calculated for Non-Hispanic Whites and seven Asian ethnic subgroups in the U.S. (Asian Indian/Pakistani, Chinese, Filipino, Hawaiian/Pacific Islander, Japanese, Korean, Vietnamese) by stage and histotype. Multivariable Cox regression analyses using a weighted approach were conducted to calculate average hazard ratios (AHRs) and 95 % confidence intervals (CIs) to quantify the risk of ovarian cancer death comparing each Asian ethnic subgroup to Non-Hispanic Whites.

RESULTS

Hawaiian/Pacific Islanders were the only Asian subgroup to show lower five-year cause-specific survival than Non-Hispanic Whites (44.99 % versus 47.90 %, respectively); Asian Indian/Pakistanis showed the highest survival (56.12 %). After adjusting for sociodemographic, tumor, and treatment characteristics, Asian Indian/Pakistani ovarian cancer patients were 17 % less likely to die from their disease whereas Hawaiian/Pacific Islander patients were 28 % more likely to die when compared to Non-Hispanic Whites (AHR = 0.83, 95 % CI 0.75-0.92 and AHR = 1.28, 95 % CI 1.07-1.53, respectively).

CONCLUSIONS

There are clear ethnic-specific survival disparities among Asian American ovarian cancer patients that are missed when the population is examined as a single group, further highlighting the need for data disaggregation in future ovarian cancer research.

The Association Between Medical Insurance, Access to Care, and Outcomes for Patients with Uveal Melanoma in the United States

PURPOSE

To investigate the association between insurance status and uveal melanoma (UM) care.

METHODS

We utilized the National Cancer Database to identify patients diagnosed with UM from 2004 to 2017. We examined the associations between patient sociodemographic characteristics, specifically insurance status, and UM care.

RESULTS

Of 7677 patients, 50% had private, 41% Medicare, 4% Medicaid, 3% other government, and 3% no insurance. Most initially received brachytherapy (66%), followed by enucleation/resection (19%) and other treatment (15%). Compared to private, Medicaid and no insurance were associated with higher odds of late-stage disease presentation (p < .05). Patients with Medicare, Medicaid, and no insurance had higher odds of enucleation/resection and lower odds of brachytherapy versus enucleation/resection (p < .05 for all). Medicaid and no insurance were associated with lower odds of other treatment versus enucleation/resection (p < .05).

CONCLUSIONS

Access barriers to UM care may exist based on insurance status and may be associated with later-stage presentation and more radical treatment.

Area Socioeconomic Status is Associated with Refusal of Recommended Surgery in Patients with Metastatic Bone and Joint Disease

BACKGROUND

This study sought to identify associations between the Yost Index, a geocoded area neighborhood socioeconomic status (nSES) score, and race/ethnicity with patient refusal of recommended surgery for metastatic bone disease.

METHODS

Patients with metastatic bone disease were extracted from the Surveillance, Epidemiology, and End Results database. The Yost Index was geocoded using factor analysis and categorized into quintiles using census tract-level American Community Service (ACS) 5-year estimates and seven nSES measures. Multivariable logistic regression models calculated odds ratios (ORs) of refusal of recommended surgery and 95% confidence intervals (CIs), adjusting for clinical covariates.

RESULTS

A total of 138,257 patients were included, of which 14,943 (10.8%) were recommended for surgical resection. Patients in the lowest nSES quintile had 57% higher odds of refusing surgical treatment than those in the highest quintile (aOR = 1.57, 95% CI 1.30-1.91, p < 0.001). Patients in the lowest nSES quintile also had a 31.2% higher age-adjusted incidence rate of not being recommended for surgery compared with those in the highest quintile (186.4 vs. 142.1 per 1 million, p < 0.001). Black patients had 34% higher odds of refusing treatment compared with White patients (aOR = 1.34, 95% CI 1.14-1.58, p = 0.003). Advanced age, unmarried status, and patients with aggressive cancer subtypes were associated with higher odds of refusing surgery (p < 0.001).

CONCLUSIONS

nSES and race/ethnicity are independent predictors of a patient refusing surgery for metastatic cancer to bone, even after adjusting for various clinical covariates. Effective strategies for addressing these inequalities and improving the access and quality of care of patients with a lower nSES and minority backgrounds are needed.

Analysis of Uveal Melanoma 5-Year Survival Rates by Medicaid Status: A Nationwide Analysis

PURPOSE

The survival outcomes of patients with primary uveal melanomas based on Medicaid status have not been previously discussed in the literature.

METHODS

The Surveillance, Epidemiology, and End Results Medicaid database were utilized to identify patients with primary uveal melanomas diagnosed between 2006 and 2013. The Kaplan-Meier method was utilized to construct 5-year survival curves in adult, non-elderly patients. Log-rank testing was used to determine differences in survival rates, and multivariate Cox proportional hazards modeling was utilized to perform adjusted survival analysis.

RESULTS

A total of 1,765 patients were included (Medicaid: 81, non-Medicaid: 1684). A total of 1683 (95.4%) were White. The average age was 51.75 years (SD = 9.5 years). Medicaid patients were more likely to be unmarried, live in a high poverty neighborhood, and live in a rural area (all p < .001). We observed no significant difference in 5-year survival rates between those enrolled in Medicaid (86.6%, 95% CI: 79.1%1-94.7%) and those not enrolled in Medicaid (85.5, 95% CI: 83.8%-87.2%) (p = .80). After controlling for socioeconomic and clinical factors, Medicaid enrollment was not associated with an increased risk of mortality compared to non-Medicaid enrollment. Age (aHR: 1.04, 95% CI: 1.02-1.06, p < .001) and tumor size >10 mm (aHR: 3.04, 95% CI: 1.49-6.21, p = .002) were associated with an increased risk of mortality.

CONCLUSION

Medicaid enrollment was not associated with worse cancer-specific 5-year survival. Further research needs to be elicited to better understand the role of Medicaid enrollment in patients with primary uveal melanoma.

Impact of the SARS-CoV-2 (COVID-19) Pandemic on Characteristics and Management of Uveal Melanoma in the National Referral Center in Poland

(1) Background: to analyze the impact of the COVID-19 pandemic on the characteristics and management of uveal melanoma (UM) in the National Referral Center in Poland. (2) Materials and Methods: the retrospective analysis of 1336 patients who were newly diagnosed with UM at the Department of Ophthalmology and Ophthalmic Oncology, Jagiellonian University Collegium Medicum Krakow, Poland between 1 January 2018 and 31 December 2021. The demographic and clinical data were compiled, including localization, size, and treatment methods of tumors. (3) Results: In total, 728 patients with UM were included before the COVID-19 pandemic, in the years 2018-2019, and 608 were included during the COVID-19 pandemic, in the years 2020-2021. Fixed-base dynamics indicators for the incidence of uveal melanoma (base year 2018) in the National Referral Center in Poland were 80.22% and 86.81% in the years 2020 and 2021, respectively. UMs were statistically significantly larger and more frequently localized anterior to the equator of the eye globe in the year 2021 than in the year 2018 (Chi-square Pearson test p = 0.0001 and p = 0.0077, respectively). The rate of patients treated with enucleation increased from 15.94% in the year 2018 to 26.90% in the year 2021 (Chi-square Pearson test p = 0.0005). (4) Conclusions: Statistically significant differences were found in the management of uveal melanoma in the National Referral Center in Poland during the COVID-19 pandemic with tumors being larger, more frequently localized anterior to the equator of the eye globe, and more often enucleated.

A prognostic nomogram for the cancer-specific survival rate of choroidal melanoma using the Surveillance, Epidemiology, and End Results database

Objective

This study was conducted to develop a comprehensive nomogram for individuals with choroidal melanoma (CM) to determine their cancer-specific survival (CSS).

Methods

Data of individuals with CM, diagnosed between 2004 and 2015, were accessed at the Surveillance, Epidemiology, and End Results (SEER) database. The selected individuals were randomly categorized into a training and validation cohort. Multivariate Cox regression analysis was applied to screen the relevant variables. Followed by the development of a nomogram based on independent variables. Ultimately, the net reclassification index (NRI), concordance index (C-index), calibration charts, integrated discrimination improvement (IDI), receiver operating characteristic curves (ROC), area under the curve (AUC), and decision-curve analysis (DCA), were utilized to evaluate the discrimination, accuracy, and effectiveness of the model.

Results

This study enrolled 3,782 patients. Seven independent factors linked to prognosis were screened via multivariate Cox regression analysis, encompassing age at diagnosis; race; AJCC (American Joint Committee on Cancer) stage; histologic type; and therapy method of radiotherapy, surgery, and chemotherapy. The respective C-indexes of the training and validation cohorts were 0.709 and 0.726, indicative of the excellent accuracy of the nomogram. Furthermore, the AUCs of the training and validation cohorts across 3, 5, and 8 years were 0.767, 0.744, and 0.722 as well as 0.772, 0.770, and 0.753, respectively. Evident of the superiority of the established nomogram over the AJCC staging, both the NRI and IDI values exhibited improvement. The favorable clinical impact and good performance of the nomogram were evident via decision curve analyses (DCAs) and calibration plots, respectively.

Conclusion

This research dealt with establishing and validating a nomogram as a prognostic tool for assessing the prognosis of adult patients with CM utilizing the SEER database. A comprehensive assessment of the nomogram via diverse variables demonstrated its accuracy in predicting the CSS probabilities of CM patients across 3, 5, and 8 years in clinical settings. Notably, its performance surpassed that of the AJCC staging system.

Assessment of Social Vulnerabilities of Care and Prognosis in Adult Ocular Melanomas in the US

BACKGROUND

Prior works have studied the impact of social determinants on various cancers but there is limited analysis on eye-orbit cancers. Current literature tends to focus on socioeconomic status and race, with sparse analysis of interdisciplinary contributions. We examined social determinants as measured by the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), quantifying eye and orbit melanoma disparities across the United States.

METHODS

A retrospective review of 15,157 patients diagnosed with eye-orbit cancers in the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2017 was performed, extracting 6139 ocular melanomas. SVI scores were abstracted and matched to SEER patient data, with scores generated by weighted averages per population density of county's census tracts. Primary outcome was months survived, while secondary outcomes were advanced staging, high grading, and primary surgery receipt.

RESULTS

With increased total SVI score, indicating more vulnerability, we observed significant decreases of 23.1% in months survival for melanoma histology (p < 0.001) and 19.6-39.7% by primary site. Increasing total SVI showed increased odds of higher grading (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.02-1.43) and decreased odds of surgical intervention (OR 0.94, 95% CI 0.92-0.96). Of the four themes, higher magnitude contributions were observed with socioeconomic status (26.0%) and housing transportation (14.4%), while lesser magnitude contributions were observed with minority language status (13.5%) and household composition (9.0%).

CONCLUSIONS

Increasing social vulnerability, as measured by the CDC SVI and its subscores, displayed significant detrimental trends in prognostic and treatment factors for adult eye-orbit melanoma. Subscores quantified which social determinants contributed most to disparities. This lays groundwork for providers to target the highest-impact social determinant for non-clinical factors in patient care.

Association of Socioeconomic Status With Worse Overall Survival in Patients With Bone and Joint Cancer

BACKGROUND

The effect of socioeconomic status (SES) on the outcomes of patients with metastatic cancer to bone has not been adequately studied. We analyzed the association between the Yost Index, a composite geocoded SES score, and overall survival among patients who underwent nonprimary surgical resection for bone metastases.

METHODS

This population-based study used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010 to 2018). We categorized bone and joint sites using International Classification of Disease-O-3 recodes. The Yost Index was geocoded using a factor analysis and categorized into quintiles using census tract-level American Community Service 5-year estimates and seven measures: median household income, median house value, median rent, percent below 150% of the poverty line, education index, percent working class, and percent unemployed. Multivariate Cox regression models were used to calculate adjusted hazard ratios of overall survival and 95% confidence intervals.

RESULTS

A total of 138,158 patients were included. Patients with the lowest SES had 34% higher risk of mortality compared with those with the highest SES (adjusted hazard ratio of 1.34, 95% confidence interval: 1.32 to 1.37, P < 0.001). Among patients who underwent nonprimary surgery of the distant bone tumor (n = 11,984), the age-adjusted mortality rate was 31.3% higher in the lowest SES patients compared with the highest SES patients (9.9 versus 6.8 per 100,000, P < 0.001). Patients in the lowest SES group showed more racial heterogeneity (63.0% White, 33.5% Black, 3.1% AAPI) compared with the highest SES group (83.9% White, 4.0% Black, 11.8% AAPI, P < 0.001). Higher SES patients are more likely to be married (77.5% versus 59.0%, P < 0.0001) and to live in metropolitan areas (99.6% versus 73.6%, P < 0.0001) compared with lower SES patients.

DISCUSSION

Our results may have implications for developing interventions to improve access and quality of care for patients from lower SES backgrounds, ultimately reducing disparities in orthopaedic surgery.

Effects of Cost Sharing on Ophthalmic Care Utilization in the Affordable Care Act Marketplace

PURPOSE

To determine the distribution and quantity of ophthalmic care consumed on Affordable Care Act (ACA) plans, the demographics of the population utilizing these services, and the relationship between ACA insurance coverage plan tier, cost sharing, and total cost of ophthalmic care consumed.

METHODS

This cross-sectional study analyzed ACA individual and small group market claims data from the Wakely Affordable Care Act (WACA) 2018 dataset, which contains detailed claims, enrollment, and premium data from Edge Servers for 3.9 million individual and small group market lives. We identified all enrollees with ophthalmology-specific billing, procedure, and national drug codes. We then analyzed the claims by plan type and calculated the total cost and out-of-pocket (OOP) cost.

RESULTS

Among 3.9 million enrollees in the WACA 2018 dataset, 538,169 (13.7%) had claims related to ophthalmology procedures, medications, and/or diagnoses. A total of $203 million was generated in ophthalmology-related claims, with $54 million in general services, $42 million in medications, $20 million in diagnostics and imaging, and $86 million in procedures. Average annual OOP costs were $116 per member, or 30.9% of the total cost, and were lowest for members with platinum plans (16% OOP) and income-driven cost sharing reduction (ICSR) subsidies (17% OOP). Despite stable ocular disease distribution across plan types, beneficiaries with silver ICSR subsidies consumed more total care than any other plan, higher than platinum plan enrollees and almost 1.5× the cost of bronze plan enrollees.

CONCLUSIONS

Ophthalmic care for enrollees on ACA plans generated substantial costs in 2018. Plans with higher OOP cost sharing may result in lower utilization of ophthalmic care.

Significance of Social Determinants of Health in Tumor Presentation, Hospital Readmission, and Overall Survival in Ocular Oncology

PURPOSE

To evaluate the association between social determinants of health (SDH) with presentation and outcomes in patients with ocular cancer.

METHODS

The National Cancer Database was queried for primary clinical tumor (cT) classifications of T1 to T4 N0M0 uveal melanoma, conjunctival melanoma, or retinoblastoma diagnosed between January 2006 and December 2017. Pearson χ2 analysis assessed differences in SDH-related characteristics between cancer cohorts. Binary logistic regression with adjusted odds ratios (aORs) and multivariate Cox proportional hazards ratios (HRs) with 95% confidence intervals (CIs) were performed.

DESIGN

Cross-sectional with a nationally representative sample.

RESULTS

Three thousand nine hundred sixty-eight uveal melanoma cases, 352 conjunctival melanoma cases, and 480 retinoblastoma cases were included. Differences in race, primary payer status, income quartile, population density, facility location, Charlson-Deyo comorbidity score, history of malignancy, cT classification at presentation, surgical treatment, radiotherapy, chemotherapy, 30-day readmission, and overall survival (OS) were observed among the cancers. Female sex (aOR 0.819 [95% CI 0.689-0.973]) and top income quartile (aOR 0.691 [95% CI 0.525-0.908]) had decreased likelihood of advanced cT classification at presentation. No insurance (aOR 1.736 [95% CI 1.159-2.601]) and Medicaid primary payer status (aOR 1.875 [95% CI 1.323-2.656]) had increased likelihood of advanced cT classification. Patients in rural areas (aOR 7.157 [95% CI 1.875-27.320]) were more likely to be readmitted within 30 days after initial treatment. Increased age was associated with decreased 5-year OS (HR 1.040 [95% CI 1.033-1.047]).

CONCLUSIONS

SDH may influence advanced cT classification at presentation and 30-day readmission compared with OS in patients with ocular cancer, highlighting the need for ophthalmologists and public health efforts to address disparities in SDH.

Uveal melanoma in the Iranian population: two decades of patient management in a tertiary eye center

BACKGROUND

To assess the characteristics and outcomes of uveal melanoma management at a tertiary center in the Middle East.

METHODS

A study on 164 patients with uveal melanoma was conducted by reviewing the available medical records, ultrasound, and pathology report results. Age at diagnosis, tumor location and size, treatment mode, visual outcome, metastasis, mortality, and survival were studied.

RESULTS

The mean age of patients was 52.0 ± 15.0 years, and 52.5% were male. Choroidal melanoma was the most common uveal melanoma, followed by the ciliary body and iris melanoma. The mean thickness of tumors was 8.29 ± 3.29. The majority of patients (n = 111, 67.9%) were managed by brachytherapy with ruthenium-106 plaques. Enucleation was performed primarily in 46 (28%) patients and secondarily in nine (5.5%) patients. The sexual disparity was detected as the proximity of uveal melanoma to the fovea in males. For a 61-month mean follow-up period, mortality occurred in eight of our cases, six of which were due to metastasis. The most common site for distance metastasis was the liver (5/6), followed by the lung (1/6). The five-year and eight-year overall survival (OS) rate was 0.947%± 0.019. The 5-year survival rate reached zero in metastatic patients. OS was not statistically different depending on the age, tumor diameters, the primary treatment received, or the histopathologic findings (p > 0.50 for all).

CONCLUSION

In this study, individuals diagnosed with UM exhibited an OS rate of around 94% at the five-year mark, which remained consistent up to eight years. Notably, the presence of distance metastasis emerged as the sole statistically significant factor influencing overall survival.

Association of Fitzpatrick Skin Type with metastatic risk from uveal melanoma in 854 consecutive patients at a single center

OBJECTIVE

To assess the association of skin color using Fitzpatrick Skin Type (FST) with metastatic risk of uveal melanoma.

SUBJECTS

854 consecutive patients with uveal melanoma and documented FST.

METHODS

Retrospective detailed review of patient charts was performed for FST (type I- white, II-fair, III-average, IV-light brown, V-brown, VI-black), clinical details of the patient and the uveal melanoma, tumor cytogenetic classification according to The Cancer Genome Atlas (TCGA), and outcome of melanoma-related metastasis and death.

RESULTS

The FST classification was type I (n = 97 patients), type II (n = 665), type III (n = 79), type IV (n = 11), type V (n = 2), type VI (n = 0). A comparison of patient FST (type I vs. II vs. III-V) revealed significant differences in mean age at presentation (64.1 vs. 58.5 vs. 49.8 years, p < 0.001), race white (100% vs. 98% vs. 75%, p < 0.001), presence of ocular melanocytosis (3% vs. 3% vs. 10%, p = 0.01), visual acuity <20/200 at presentation (6% vs. 7% vs. 13%, p = 0.03), genetic results showing TCGA group B tumors (11% vs. 14% vs. 26%, p = 0.01) or TCGA group D tumors (22% vs. 11% vs. 9%, p = 0.01), 10-year incidence of melanoma-related metastasis (25% vs. 15% vs. 14%, p = 0.02) and 10-year incidence of melanoma-related death (9% vs. 3% vs. 4%, p = 0.04). FST was a significant predictor of melanoma-related metastasis (p = 0.02, Hazard ratio 2.3).

CONCLUSIONS

Fitzpatrick skin type may be a predictor of melanoma-related metastasis, with metastasis and TCGA Group D tumors being more common in patients with FST I.

Ensuring Safety While Achieving Beauty: An Evidence-Based Approach to Optimizing Mastectomy and Autologous Breast Reconstruction Outcomes in Patients with Obesity

BACKGROUND

Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients.

STUDY DESIGN

This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies.

RESULTS

We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021).

CONCLUSIONS

Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction.

Uveal melanoma in African Americans: Diagnostic challenges

Uveal melanoma (UM) is uncommon in African Americans. Owing to its rarity, UM may not be suspected in African Americans leading to delayed diagnosis. In addition, socioeconomic factors may also play a role in delayed diagnosis. Clinical and ultrasonographic features may be atypical due to racial pigmentation, necessitating diagnostic fine needle aspiration biopsy. Herein, we report an illustrative case series of 12 African Americans with UM highlighting clinical features and diagnostic challenges.

Sex Differences in the Treatment of Uveal Melanoma in a Group of 1336 Patients

(1) Background: The aim of this study was to analyze the sex differences in the treatment of uveal melanoma (UM) in a group of 1336 patients from a national referral center during the period 2018-2021. (2) Materials and Methods: The study was designed in a retrospective manner. A total of 1336 patients who were newly diagnosed with UM at the Department of Ophthalmology and Ophthalmic Oncology, Jagiellonian University Collegium Medicum, Krakow, Poland, between 1 January 2018 and 31 December 2021, were included in the study. The demographic and clinical data were compiled, including the sex of patients and the treatment methods. (3) Results: In total, 1336 patients with ocular melanoma were identified, including 726 women (54.34%) and 610 men (45.66%). A total of 49.70% of tumors were localized in the right eye and 50.30% in the left eye. UMs were localized statistically significantly more frequently posterior to the equator of the eye globe in men than in women (79.67% vs. 74.10%, Chi^2 Pearson test p = 0.035). Tumors tended to be larger in men, but this difference was not clinically significant. Men were enucleated more often than women (23.44% vs. 18.04%, Chi^2 Pearson test p = 0.015). (4) Conclusions: Statistically significant sex differences were found in the treatment of uveal melanoma in a national referral center in Poland, with men being enucleated more often than women.

Area Deprivation Index is Associated with Variation in Quality of Life and Psychosocial Well-being Following Breast Cancer Surgery

BACKGROUND

Neighborhood-level factors have been shown to influence surgical outcomes through material deprivation, psychosocial mechanisms, health behaviors, and access to resources. To date, no study has examined the relationship between area-level deprivation (ADI) and post-mastectomy outcomes.

METHODS

A cross-sectional survey of adult female breast cancer patients who underwent lumpectomy or mastectomy between January 2018 to June 2019 was carried out. Patient-specific characteristics and ADI information were abstracted and correlated with postoperative global- (SF-12) and condition-specific (BREAST-Q) quality-of-life performance via multivariable regression. Patients were classified into three ADI terciles: 0-39 (low deprivation), 40-59 (moderate deprivation), and 60-100 (high deprivation).

RESULTS

A total of 564 consecutive patients were identified, being mostly white (75%) with mean age of 60.2 ± 12.4 years, median body mass index of 27.8 [interquartile range (IQR) 24.3-32.2) kg/m², median Charlson Comorbidity Index of 3 (IQR 2-5), and mean ADI of 42.3 ± 25.7. African American and Hispanic patients and those with high BMI were more likely to reside in highly deprived neighborhoods (p = 0.003 and p < 0.001). In adjusted models, patients in highly deprived neighborhoods had significantly lower mean SF-12 physical (44.9 [95% CI, 43.8-46.0] versus 44.9 [95% CI, 43.7-46.1] versus 46.3 [95% CI, 45.3-47.3], p = 0.03) and BREAST-Q psychosocial well-being scores (63.5 [95% CI, 59.32-67.8] versus 69.3 [95% CI, 65.1-73.6] versus 69.7 [95% CI, 66.4-73.1], p = 0.01) relative to moderate- and low-deprivation groups.

CONCLUSIONS

Patients residing in the most deprived neighborhoods were identified to have worse psychological well-being and quality-of-life. The ADI should be incorporated into the shared decision-making process and perioperative counseling to engender value-based and personalized care, especially for vulnerable populations.

Characteristics, Treatments, and Survival of Uveal Melanoma: A Comparison between Chinese and American Cohorts

Simple Summary

This retrospective comparative cohort study aimed to determine whether there were racial or national differences in UM, by comparing the demographic and clinical characteristics, such as tumor size, onset age, trend and proportion of treatment modalities, and overall survival. In the two cohorts, we found that Chinese patients have a younger onset age and a better survival rate. The survival advantage was likely secondary to younger onset age. In addition, a greater proportion of Chinese patients received brachytherapy as opposed to enucleation compared with American patients. This study was the first time comparing patients from different countries and races, which may help ophthalmologists better understand the clinical characteristics of the disease and suggests the importance of early diagnosis and treatment.

Abstract

Uveal melanoma (UM) is the most common intraocular malignant carcinoma. This study aimed to compare the clinical features, treatment modalities, and prognosis of UM patients in China with those in America over a 15-year period. In the study, 4088 American patients with primary UM from the Surveillance, Epidemiology, and End Results (SEER) database and 1508 Chinese patients from Tongren-ophthalmology Research Association of Clinical Evaluation (TRACE) were included. Univariable and multivariable analyses were performed to determine prognostic factors and propensity score matching (PSM) and sensitivity analyses were applied to adjust for confounders and identify independent prognostic factors. Chinese patients were diagnosed at a younger age (mean ± SD, 47.3 ± 12.5 years vs. 59.7 ± 14.8 years) and tumors at diagnosis were larger (diameter: 12.0 ± 3.54 mm vs. 11.3 ± 8.27 mm; thickness: 7.13 ± 3.28 mm vs. 4.91 ± 3.01 mm). Chinese patients were more likely to undergo brachytherapy than American patients. Chinese patients had better overall survival than American patients while no significant differences exhibited after adjusting for age through PSM. In conclusion, compared with American patients, Chinese patients had younger onset age, larger tumors at diagnosis and better prognosis, mainly because of their younger age.

Efficacy and mechanism of anti-vascular endothelial growth factor drugs for diabetic macular edema patients

BACKGROUND

Diabetes is a serious public health concern in China, with 30% of patients developing retinopathy, and diabetic macular edema (DME) having the biggest impact on vision. High blood glucose level can cause retinal cell hypoxia, thus promoting vascular endothelial growth factor (VEGF) formation and increasing vascular permeability, which induces DME. Moreover, cell hypoxia can accelerate the rate of apoptosis, which leads to the aging of patients. In severe cases, optic cell apoptosis or retinal fibrosis and permanent blindness may occur.

AIM

To investigate and compare the efficacy, mechanism, and differences between two anti-VEGF drugs (Compaq and ranibizumab) in DME patients.

METHODS

Ninety-six patients with DME who attended our hospital from April 2018 to February 2020 were included and randomly divided into two groups (Compaq group and ranibizumab group). The groups received vitreal cavity injections of 0.5 mg Compaq and 0.5 mg ranibizumab, respectively, once a month. The best corrected visual acuity (BCVA), intraocular pressure (IOP), macular retinal thickness (CMT), macular choroidal thickness (SFCT), foveal no perfusion area (FAZ), superficial capillary density, deep capillary density, treatment effect, and adverse reactions were compared before and after treatment and between the two groups.

RESULTS

Before treatment and 1-mo post-treatment, there was no statistically significant difference in the estimated BCVA in both groups (P > 0.05). BCVA decreased in the Compaq group 3 mo after treatment, and the difference was statistically significant (P < 0.05). Before treatment, and 1 mo and 3 mo post-treatment, there was no statistically significant difference in the estimated IOP in either group (P > 0.05). Before treatment and 1-mo post-treatment, there was no statistically significant difference in the estimated CMT, SFCT, or FAZ in either group (P > 0.05). CMT and SFCT values decreased in the Compaq group 3 mo post-treatment, and the difference was statistically significant (P < 0.05). Before treatment, and 1 mo and 3 mo post-treatment, there were no statistically significant differences in vascular density in the shallow or deep capillary plexi of the fovea, parafovea, or overall macular area between the two groups (P > 0.05). Marked efficient, effective, and invalid rates were 70.83% and 52.08%, 27.08% and 39.58%, and 2.08% and 8.33% in the Compaq and ranibizumab groups, respectively. The differences between the two groups were statistically significant (P < 0.05).

CONCLUSION

Anti-VEGF drugs can effectively improve CMT and SFCT, without affecting microcirculation, thus providing an effective and safe treatment for patients with DME.

Estimating uncertainty in a socioeconomic index derived from the American community survey

Socioeconomic indexes are widely used in public health to facilitate neighborhood-scale analyses. Although they are calculated with high levels of precision, they are rarely reported with accompanying measures of uncertainty (e.g., 90% confidence intervals). Here we use the variance replicate tables that accompany the United States Census Bureau's American Community Survey to report confidence intervals around the Yost Index, a socioeconomic index comprising seven variables that is frequently used in cancer surveillance. The Yost Index is reported as a percentile score from 1 (most affluent) to 100 (most deprived). We find that the average uncertainty for a census tract in the United States is plus or minus 8 percentiles, with the uncertainty a function of the value of the index itself. Scores at the extremes of the distribution are more precise and scores near the center are less precise. Less-affluent tracts have greater uncertainty than corresponding more-affluent tracts. Fewer than 50 census tracts of 72,793 nationally have unusual distributions of socioeconomic conditions that render the index uninformative. We demonstrate that the uncertainty in a census-based socioeconomic index is calculable and can be incorporated into any analysis using such an index.

Association of Race, Ethnicity, and Socioeconomic Status With Esthesioneuroblastoma Presentation, Treatment, and Survival

Objective

Socioeconomic and other demographic factors are associated with outcomes in head and neck cancer. This study uses a national cancer database to explore how patient race, ethnicity, and socioeconomic status (SES) are associated with esthesioneuroblastoma outcomes, including 5-year disease-specific survival (DSS), conditional DSS, stage at diagnosis, and treatment.

Study Design

Retrospective cohort analysis.

Setting

Patients with esthesioneuroblastomas between 1973 and 2015 from the SEER registry (Surveillance, Epidemiology, and End Results).

Methods

The National Cancer Institute Yost Index, a census tract–level composite score composed of 7 parameters, was used to categorize the SES of patients. Kaplan-Meier analysis and Cox regression were conducted to assess DSS. Conditional DSS was calculated per estimates from simplified Cox models. Logistic regression was conducted to identify risk factors for advanced cancer stage at diagnosis and the likelihood of receiving multimodal therapy.

Results

Complete data were included for 561 patients. DSS was significantly associated with SES (log-rank, P < .01) but not race. According to Cox regression, DSS was worse for the lowest SES tertile vs the highest (hazard ratio, 1.70 [95% CI, 1.05-2.75]; P = .03). Patients of the lowest SES tertile exhibited an increased risk of advanced cancer stage at diagnosis as compared with the highest SES tertile (odds ratio, 1.84 [95% CI, 1.06-3.30]; P = .035). Black patients (odds ratio, 0.44 [95% CI, 0.24-0.84]; P = .011) were less likely than other patients to receive multimodal therapy. SES alone was not associated with receiving multimodal therapy.

Conclusion

SES is significantly associated with DSS and conditional DSS for patients with esthesioneuroblastomas. Inequalities in access to care and treatment likely contribute to these disparities.

Prognosis Prediction of Uveal Melanoma After Plaque Brachytherapy Based on Ultrasound With Machine Learning

INTRODUCTION

Uveal melanoma (UM) is the most common intraocular malignancy in adults. Plaque brachytherapy remains the dominant eyeball-conserving therapy for UM. Tumor regression in UM after plaque brachytherapy has been reported as a valuable prognostic factor. The present study aimed to develop an accurate machine-learning model to predict the 4-year risk of metastasis and death in UM based on ocular ultrasound data.

MATERIAL AND METHODS

A total of 454 patients with UM were enrolled in this retrospective, single-center study. All patients were followed up for at least 4 years after plaque brachytherapy and underwent ophthalmologic evaluations before the therapy. B-scan ultrasonography was used to measure the basal diameters and thickness of tumors preoperatively and postoperatively. Random Forest (RF) algorithm was used to construct two prediction models: whether a patient will survive for more than 4 years and whether the tumor will develop metastasis within 4 years after treatment.

RESULTS

Our predictive model achieved an area under the receiver operating characteristic curve (AUC) of 0.708 for predicting death using only a one-time follow-up record. Including the data from two additional follow-ups increased the AUC of the model to 0.883. We attained AUCs of 0.730 and 0.846 with data from one and three-time follow-up, respectively, for predicting metastasis. The model found that the amount of postoperative follow-up data significantly improved death and metastasis prediction accuracy. Furthermore, we divided tumor treatment response into four patterns. The D(decrease)/S(stable) patterns are associated with a significantly better prognosis than the I(increase)/O(other) patterns.

CONCLUSIONS

The present study developed an RF model to predict the risk of metastasis and death from UM within 4 years based on ultrasound follow-up records following plaque brachytherapy. We intend to further validate our model in prospective datasets, enabling us to implement timely and efficient treatments.

Impact of Race, Ethnicity, and Socioeconomic Status on Nasopharyngeal Carcinoma Disease-Specific and Conditional Survival

Introduction  Race, ethnicity, and socioeconomic status (SES) are complex, interconnected social determinants of health outcomes. This study uses multivariable analysis on a combination of large national datasets to examine the effects of these factors on 5-year disease-specific survival (DSS) and conditional DSS (CDSS) for nasopharyngeal carcinoma (NPC). Methods  A retrospective study of adults with NPC between 2000 and 2017 from the Surveillance, Epidemiology, End Results (SEER) registry was performed, using the National Cancer Institute Yost Index, a census tract-level composite score of SES to categorize patients. Kaplan-Meier analysis and Cox's regression for DSS and CDSS were stratified by SES. Logistic regression was conducted to identify risk factors for advanced cancer stage at time of diagnosis and receiving multimodal therapy. Results  Our analysis included 5,632 patients. DSS was significantly associated with race and SES ( p  < 0.01). Asian/Pacific Islander patients exhibited increased survival when controlling for other variables (hazard ratio [HR] = 0.73, p  < 0.01). Although Black patients were more likely to be diagnosed with advanced disease (Black odds ratio [OR] = 1.47, p  < 0.01), Black patients were also less likely to receive multimodal therapy; however, this relationship lost statistical significance once SES was incorporated into the multivariable analysis. DSS was decreased among the lowest (first) and middle (second) tertiles of SES (first HR = 1.34, p  < 0.01; second HR = 1.20, p  < 0.01) compared with the highest (third). Conclusion  Our results indicate that race, ethnicity, and SES significantly affect survival, stage at diagnosis, and treatment of NPC. An interplay of tumor biology and inequalities in access to care likely drives these disparities.

Impact of Socioeconomic Status on Paranasal Sinus Cancer Disease-Specific and Conditional Survival

OBJECTIVE

Socioeconomic status (SES) is often used to quantify social determinants of health. This study uses the National Cancer Institute SES index to examine the effect of SES on disease-specific survival and 5-year conditional disease-specific survival (CDSS; the change in life expectancy with increasing survivorship) in paranasal sinus cancer.

STUDY DESIGN

Cross-sectional analysis.

SETTING

National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program.

METHODS

A study of adults with sinus cancer between 1973 and 2015 was performed. The Yost index, a census tract-level composite score of SES, was used to categorize patients. Kaplan-Meier analysis and Cox regression for disease-specific survival were stratified by SES. CDSS was calculated with simplified models. Logistic regression was conducted to identify risk factors for advanced stage at diagnosis, multimodal therapy, and diagnosis of squamous cell carcinoma.

RESULTS

There were 3437 patients analyzed. In Cox models adjusting for patient-specific factors, the lowest SES tertile exhibited worse mortality (hazard ratio, 1.22; 95% CI, 1.07-1.39; P < .01). After addition of treatment and pathology, SES was not significant (P = .07). The lowest SES tertile was more often diagnosed at later stages (odds ratio [OR], 1.52; 95% CI, 1.12-2.06; P < .01). For those with regional/distant disease, the middle tertile (OR, 0.75; 95% CI, 0.63-0.90; P < .01) and lowest tertile (OR, 0.75; 95% CI, 0.62-0.91; P < .01) were less likely to receive multimodal therapy. SES tertiles primarily affected 5-year CDSS for regional/distant disease. CDSS for all stages converged over time.

CONCLUSION

Lower SES is associated with worse outcomes in paranasal sinus cancer. Research should be devoted toward understanding factors that contribute to such disparities, including tumor pathology and treatment course.

The Influence of Marital Status on the Survival of Patients with Uveal Melanoma

Background

Uveal melanoma (UM) is the most common primary intraocular tumor in adults and arises from the uvea. Marital status was a vital factor among physical conditions and social networks of cancer patients. Our study aimed to evaluate the impact of marital status on the outcomes among patients with UM.

Methods

Patients with UM newly diagnosed from 2004 to 2015 were extracted, and the data were extracted from Surveillance, Epidemiology, and End Results (SEER) program. Overall survival (OS) was measured via the log-rank test, as well as cancer-specific survival (CSS) was also calculated via the same method. Cox proportional hazards models were applied to assess whether marital status was related to both OS and CSS. Furthermore, we performed subgroup analysis depending on different sexes and SEER stages.

Results

In total, 4217 eligible patients were involved. Of these patients, 66.2% (n = 2793) were married, 14.6% (n = 615) were single, and 9.0% (n = 379) were divorced or separated, as well as widowed were 10.2% (n = 430). The 5-year OS of married, single, divorced or separated, and widowed patients was 74.0%, 72.8%, 68.6%, and 55.8%, respectively. The results indicating better OS and CSS occurred among married patients. Other factors such as sex, age at diagnosis, and SEER stage were also correlated with survival in UM patients. Furthermore, subgroup analyses were consistent with the results above.

Conclusion

Marital status was proved to be an independent prognostic value for survival in UM patients. In addition, contrast to married patients, widowed individuals showed poor OS and CSS at different subgroup analyses.

A Novel Nomogram and Risk Classification System Predicting the Cancer-Specific Mortality of Patients with Initially Diagnosed Metastatic Cutaneous Melanoma

BACKGROUND

Cutaneous melanoma and distant organ metastasis has varying outcomes. Considering all prognostic indicators in a prediction model might assist in selecting cases who could benefit from a personalized therapy strategy.

OBJECTIVE

This study aimed to develop and validate a prognostic model for patients with metastatic melanoma.

METHODS

A total of 1535 cases diagnosed with metastatic cutaneous melanoma (stage IV) were identified from the Surveillance, Epidemiology, and End Results database. Patients were randomly divided into the training (n = 1023) and validation (n = 512) cohorts. A prognostic nomogram was established based predominantly on results from the competing-risk regression model for predicting cancer-specific death (CSD). The area under the time-dependent receiver operating characteristic curve (AUC), calibration curves, and decision curve analyses (DCAs) were used to evaluate the nomogram.

RESULTS

No significant differences were observed in the clinical characteristics between the training and validation cohorts. In the training cohort, patient-, tumor-, and treatment-related predictors of CSD for metastatic melanoma included age, sex, race, marital status, insurance, American Joint Committee on Cancer T and N stage, number of metastatic organs, surgical treatment, and chemotherapy. All these factors were used for nomogram construction. The time-dependent AUC values of the training and validation cohorts suggested a favorable performance and discrimination of the nomogram. The 6-, 12-, and 18-month AUC values were 0.706, 0.700, and 0.706 in the training cohort, and 0.702, 0.670, and 0.656 in the validation cohort, respectively. The calibration curves for the probability of death at 6, 12, and 18 months showed acceptable agreement between the values predicted by the nomogram and the observed outcomes in both cohorts. DCA curves showed good positive net benefits in the prognostic model among most of the threshold probabilities at different time points (death at 6, 12, and 18 months). Based on the total nomogram scores of each case, all patients were divided into the low-risk (n = 511), intermediate-risk (n = 512), and high-risk (n = 512) groups, and the risk classification could identify cases with a high risk of death in both cohorts.

CONCLUSIONS

A predictive nomogram and a corresponding risk classification system for CSD in patients with metastatic melanoma were developed in this study, which may assist in patient counseling and in guiding clinical decision making for cases with metastatic melanoma.