Racial, ethnic and socioeconomic disparities in the treatment of brain tumors

Racial/ethnic disparities in all-cause and cause-specific death among children with malignant central nervous system tumours: a registry-based cohort retrospective analysis

Background

It is generally recognized that there is unequal mortality in childhood central nervous system (CNS) malignancy in the United States (US), but little is known about the trends and contributors of racial/ethnic disparities in death. We assessed the trends of racial/ethnic disparities in all-cause and cause-specific death, and the contributions of tumour, treatment and socioeconomic factors to this disparity.

Methods

This registry-based cohort study included children (aged ≤19 years) diagnosed with malignant CNS tumours, using data from the US population-based cancer registry in the Surveillance, Epidemiology, and End Results (SEER) Program. The clinical outcomes were all-cause and cause-specific death for each racial/ethnic group (White, Black, Hispanic, non-Hispanic Asian/Pacific Islander [API], and non-Hispanic American Indian/Alaska Native [AI/AN] children). We quantified absolute disparities using absolute rate difference in 5-year cumulative incidence of death. Cox proportion risk models were used to estimate the relative racial/ethnic disparities, and the contribution of factors to disparities in death.

Findings

In this study, data from 14,510 children with malignant CNS tumours (mean [SD] age, 8.5 [5.7]; 7988 [55.1%] male) were analysed. Overall, the cumulative incidence of death from CNS tumours across four racial/ethnic groups decreased from 2001 to 2020. Black patients had the highest risk of death from all causes and CNS tumours between 2001 and 2020, with adjusted hazard ratios (HR) of 1.52 (1.38-1.68) and 1.47 (1.31-1.64), respectively. The absolute disparity in all-cause death between Hispanic and White patients increased slightly (from 8.2 percentage points [ppt] to 9.4 ppt), and the relative disparity in death from CNS tumours increased from 1.33 (1.15-1.55) in 2001-2005 to 1.78 (1.44-2.20) in 2016-2020. The absolute disparities in death from CNS tumours between Black and White patients (from 11.8 ppt to 4.3 ppt) and between API and White patients (from 10.1 ppt to 5.1 ppt) decreased from 2001-2005 to 2011-2015.

Interpretation

Race/ethnicity disparities in death from CNS tumours among childhood malignant CNS tumours had reduced from 2001 to 2020, and quantifying the contribution of factors to this disparity in death could provide a basis for decreasing mortality among racial/ethnic minority patients.

Funding

Shenyang Young and Middle-aged Science and Technology Innovation Talent Support Program.

Enhancing neuro-oncology care through equity-driven applications of artificial intelligence

The disease course and clinical outcome for brain tumor patients depend not only on the molecular and histological features of the tumor but also on the patient's demographics and social determinants of health. While current investigations in neuro-oncology have broadly utilized artificial intelligence (AI) to enrich tumor diagnosis and more accurately predict treatment response, postoperative complications, and survival, equity-driven applications of AI have been limited. However, AI applications to advance health equity in the broader medical field have the potential to serve as practical blueprints to address known disparities in neuro-oncologic care. In this consensus review, we will describe current applications of AI in neuro-oncology, postulate viable AI solutions for the most pressing inequities in neuro-oncology based on broader literature, propose a framework for the effective integration of equity into AI-based neuro-oncology research, and close with the limitations of AI.

Clinicosocial determinants of hospital stay following cervical decompression: A public healthcare perspective and machine learning model

OBJECTIVE

Post-operative length of hospital stay (LOS) is a valuable measure for monitoring quality of care provision, patient recovery, and guiding hospital resource management. But the impact of patient ethnicity, socio-economic deprivation as measured by the indices of multiple deprivation (IMD), and pre-existing health conditions on LOS post-anterior cervical decompression and fusion (ACDF) is under-researched in public healthcare settings.

METHODS

From 2013 to 2023, a retrospective study at a single center reviewed all ACDF procedures. We analyzed 14 non-clinical predictors-including demographics, comorbidities, and socio-economic status-to forecast a categorized LOS: short (≤2 days), medium (2-3 days), or long (>3 days). Three machine learning (ML) models were developed and assessed for their prediction reliability.

RESULTS

2033 ACDF patients were analyzed; 79.44 % had a LOS ≤ 2 days. Significant predictors of LOS included patient sex (HR:0.81[0.74-0.88], p < 0.005), IMD decile (HR:1.38[1.24-1.53], p < 0.005), smoking (HR:1.24[1.12-1.38], p < 0.005), DM (HR:0.70[0.59-0.84], p < 0.005), and COPD (HR:0.66, p = 0.01). Asian patients had the highest mean LOS (p = 0.003). Testing on 407 patients, the XGBoost model achieved 80.95 % accuracy, 71.52 % sensitivity, 85.76 % specificity, 71.52 % positive predictive value, and a micro F1 score of 0.715. This model is available at: https://acdflos.streamlit.app.

CONCLUSIONS

Utilizing non-clinical pre-operative parameters such as patient ethnicity, socio-economic deprivation index, and baseline comorbidities, our ML model effectively predicts postoperative LOS for patient undergoing ACDF surgeries. Yet, as the healthcare landscape evolves, such tools will require further refinement to integrate peri and post-operative variables, ensuring a holistic decision support tool.

Managing vestibular schwannomas with radiosurgery and radiotherapy: AGREE II appraisal of clinical practice guidelines

INTRODUCTION

Vestibular schwannomas (VSs) are rare, benign intracranial tumours that have prompted clinical practice guideline (CPG) creation given their complex management. Our aim was to utilize the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument to assess if such CPGs on the management of VSs with radiosurgery and radiotherapy are of acceptable quality.

METHODS

Relevant CPGs were identified following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols. Experienced reviewers then extracted general CPG properties and rated their quality via the AGREE II instrument. Intraclass correlation coefficients (ICCs) were quantified to assess interrater reliability.

RESULTS

Nine CPGs on the management of VSs with radiosurgery and radiotherapy were identified. All CPGs were created in the past six years and developed recommendations based on literature review and expert consensus. One guideline was deemed as high quality with seven others being moderate and one being low in quality. The clarity of the presentation domain had the highest mean scaled domain score of 96.0%. The domains of stakeholder involvement and applicability had the lowest means of 49.2% and 47.2%, respectively. ICCs were either good or excellent across all domains.

CONCLUSION

Current CPGs on the management of VSs with radiosurgery and radiotherapy are of acceptable quality but would greatly benefit from improvements in applicability, stakeholder involvement, editorial independence and rigour of development. We recommend CPG authors reference the European Association of Neuro-Oncology (EANO) guideline as a developmental framework with the Congress of Neurological Surgeons/American Association of Neurological Surgeons (CNS/AANS) CPG being a valid alternative.

Defining interventions and metrics to improve diversity in CNS clinical trial participation: A SNO and RANO effort

Despite major strides in cancer research and therapy, these advances have not been equitable across race and ethnicity. Historically marginalized groups (HMG) are more likely to have inadequate preventive screening, increased delays in diagnosis, and poor representation in clinical trials. Notably, Black, Hispanic, and Indigenous people represent 30% of the population but only 9% of oncology clinical trial participants. As a result, HMGs lack equitable access to novel therapies, contradicting the principle of distributive justice, as enshrined in the Belmont report, which demands the equitable selection of subjects in research involving human subjects. The lack of clinical trial diversity also leads to low generalizability and potentially harmful medical practices. Specifically, patients with brain cancer face unique barriers to clinical trial enrollment and completion due to disease-specific neurologic and treatment-induced conditions. Collectively, the intersection of these disease-specific conditions with social determinants of health fosters a lack of diversity in clinical trials. To ameliorate this disparity in neuro-oncology clinical trial participation, we present interventions focused on improving engagement of HMGs. Proposals range from inclusive trial design, decreasing barriers to care, expanding trial eligibility, access to tumor profiling for personalized medical trials, setting reasonable metrics and goals for accrual, working with patient community stakeholders, diversifying the neuro-oncology workforce, and development of tools to overcome biases with options to incentivize equity. The diversification of participation amongst neuro-oncology clinical trials is imperative. Equitable access and inclusion of HMG patients with brain tumors will not only enhance research discoveries but will also improve patient care.

Association of county-level socioeconomic status with meningioma incidence and outcomes

BACKGROUND

Prior literature suggests that individual socioeconomic status (SES) may influence incidence, treatments, and survival of brain tumor cases. We aim to conduct the first national study to evaluate the association between US county-level SES and incidence, treatment, and survival in meningioma.

METHODS

The Central Brain Tumor Registry of the United States analytic dataset, which combines data from CDC's National Program of Cancer Registries (NPCR) and National Cancer Institute's Surveillance, Epidemiology, and End Results Program, was used to identify meningioma cases from 2006 to 2019. SES quintiles were created using American Community Survey data. Logistic regression models were used to evaluate associations between SES and meningioma. Cox proportional hazard models were constructed to assess the effect of SES on survival using the NPCR analytic dataset.

RESULTS

A total of 409 681 meningioma cases were identified. Meningioma incidence increased with higher county-level SES with Q5 (highest quintile) having a 12% higher incidence than Q1 (incidence rate ratios (IRR) = 1.12, 95%CI: 1.10-1.14; P < .0001). The Hispanic group was the only racial-ethnic group that had lower SES associated with increased meningioma incidence (Q5: age-adjusted incidence ratio (AAIR) = 9.02, 95%CI: 8.87-9.17 vs. Q1: AAIR = 9.33, 95%CI: 9.08-9.59; IRR = 0.97, 95%CI: 0.94-1.00; P = .0409). Increased likelihood of surgical treatment was associated with Asian or Pacific Islander non-Hispanic individuals (compared to White non-Hispanic (WNH)) (OR = 1.28, 95%CI: 1.23-1.33, P < .001) and males (OR = 1.31, 95%CI: 1.29-1.33, P < .001). Black non-Hispanic individuals (OR = 0.90, 95%CI: 0.88-0.92, P < .001) and those residing in metropolitan areas (OR = 0.96, 95%CI: 0.96-0.96, P < .001) were less likely to receive surgical treatment compared to WNH individuals. Overall median survival was 137 months, and survival was higher in higher SES counties (Q5 median survival = 142 months).

CONCLUSIONS

Higher county-level SES was associated with increased meningioma incidence, surgical treatment, and overall survival. Racial-ethnic stratification identified potential disparities within the meningioma population. Further work is needed to understand the underpinnings of socioeconomic and racial disparities for meningioma patients.

High costs, low quality of life, reduced survival, and room for improving treatment: an analysis of burden and unmet needs in glioma

Gliomas are a group of heterogeneous tumors that account for substantial morbidity, mortality, and costs to patients and healthcare systems globally. Survival varies considerably by grade, histology, biomarkers, and genetic alterations such as IDH mutations and MGMT promoter methylation, and treatment, but is poor for some grades and histologies, with many patients with glioblastoma surviving less than a year from diagnosis. The present review provides an introduction to glioma, including its classification, epidemiology, economic and humanistic burden, as well as treatment options. Another focus is on treatment recommendations for IDH-mutant astrocytoma, IDH-mutant oligodendroglioma, and glioblastoma, which were synthesized from recent guidelines. While recommendations are nuanced and reflect the complexity of the disease, maximum safe resection is typically the first step in treatment, followed by radiotherapy and/or chemotherapy using temozolomide or procarbazine, lomustine, and vincristine. Immunotherapies and targeted therapies currently have only a limited role due to disappointing clinical trial results, including in recurrent glioblastoma, for which the nitrosourea lomustine remains the de facto standard of care. The lack of treatment options is compounded by frequently suboptimal clinical practice, in which patients do not receive adequate therapy after resection, including delayed, shortened, or discontinued radiotherapy and chemotherapy courses due to treatment side effects. These unmet needs will require significant efforts to address, including a continued search for novel treatment options, increased awareness of clinical guidelines, improved toxicity management for chemotherapy, and the generation of additional and more robust clinical and health economic evidence.

Prognostic Factors and Nomogram for Choroid Plexus Tumors: A Population-Based Retrospective Surveillance, Epidemiology, and End Results Database Analysis

Background: Choroid plexus tumors (CPTs) are rare neoplasms found in the central nervous system, comprising 1% of all brain tumors. These tumors include choroid plexus papilloma (CPP), atypical choroid plexus papilloma (aCPP), and choroid plexus carcinoma (CPC). Although gross total resection for choroid plexus papillomas (CPPs) is associated with long-term survival, there is a scarcity of prospective data concerning the role and sequence of neoadjuvant therapy in treating aCPP and CPC. Methods: From the years 2000 to 2019, 679 patients with CPT were identified from the Surveillance, Epidemiology, and End Result (SEER) database. Among these patients, 456 patients had CPP, 75 patients had aCPP, and 142 patients had CPC. Univariate and multivariable Cox proportional hazard models were run to identify variables that had a significant impact on the primary endpoint of overall survival (OS). A predictive nomogram was built for patients with CPC to predict 5-year and 10-year survival probability. Results: Histology was a significant predictor of OS, with 5-year OS rates of 90, 79, and 61% for CPP, aCPP, and CPC, respectively. Older age and African American race were prognostic for worse OS for patients with CPP. Older age was also associated with reduced OS for patients with aCPP. American Indian/Alaskan Native race was linked to poorer OS for patients with CPC. Overall, treatment with gross total resection or subtotal resection had no difference in OS in patients with CPP or aCPP. Meanwhile, in patients with CPC, gross total resection (GTR) was associated with significantly better OS than subtotal resection (STR) only. However, there is no difference in OS between patients that receive GTR and patients that receive STR with adjuvant therapy. The nomogram for CPC considers types of treatments received. It demonstrates acceptable accuracy in estimating survival probability at 5-year and 10-year intervals, with a C-index of 0.608 (95% CI of 0.446 to 0.77). Conclusions: This is the largest study on CPT to date and highlights the optimal treatment strategies for these rare tumors. Overall, there is no difference in OS with GTR vs. STR in CPP or aCPP. Furthermore, OS is equivalent for CPC with GTR and STR plus adjuvant therapy.

Social Determinants of Health and Associations With Outcomes in Pediatric Patients With Brain Tumors

BACKGROUND AND OBJECTIVES

Social determinants of health (SDOH) are nonmedical factors that affect health outcomes. Limited investigation has been completed on the potential association of these factors to adverse outcomes in pediatric populations. In this study, the authors aimed to analyze the effects of SDOH disparities and their relationship with outcomes after brain tumor resection or biopsy in children.

METHODS

The authors retrospectively reviewed the records of their center's pediatric patients with brain tumor. Black race, public insurance, median household income, and distance to hospital were the investigated SDOH factors. Univariate analysis was completed between number of SDOH factors and patient demographics. Multivariate linear regression models were created to identify coassociated determinants and outcomes.

RESULTS

A total of 272 patients were identified and included in the final analysis. Among these patients, 81 (29.8%) had no SDOH disparities, 103 (37.9%) had 1, 71 (26.1%) had 2, and 17 (6.2%) had 3. An increased number of SDOH disparities was associated with increased percentage of missed appointments ( P = .002) and emergency room visits ( P = .004). Univariate analysis demonstrated increased missed appointments ( P = .01), number of postoperative imaging ( P = .005), and number of emergency room visits ( P = .003). In multivariate analysis, decreased median household income was independently associated with increased length of hospital stay ( P = .02).

CONCLUSION

The SDOH disparities are prevalent and impactful in this vulnerable population. This study demonstrates the need for a shift in research focus toward identifying the full extent of the impact of these factors on postoperative outcomes in pediatric patients with brain tumor.

Disparities in Neuro-Oncology

PURPOSEOF REVIEW

Health disparities are preventable differences in the diagnosis, treatment, and outcomes of many diseases, including central nervous system (CNS) tumors. This review will summarize and compile the existing literature on health disparities in neuro-oncology and provide directions for future research and interventions.

RECENT FINDINGS

Patients from historically marginalized groups are more likely to receive inadequate treatment, develop complications, and experience a shorter life expectancy. Financial toxicity can be particularly severe for patients with CNS tumors due to the high costs of treatment. Additionally, CNS clinical trials and research lack diverse representation.

Social disparities in sleep health of African populations: A systematic review and meta-analysis of observational studies

OBJECTIVES

To document the relationship between socioeconomic status (SES) and sleep health in African populations.

METHODS

Observational cross-sectional or cohort studies examining the association between SES indicators and sleep outcomes in participants from African countries were included. The search was performed in the MEDLINE, Embase, and Web of Science Core Collection electronic databases in June 2021. Selection, confounding, attrition/exclusion, detection, and selective reporting bias were assessed using the OHAT Risk of Bias Tool. Random effects meta-analysis was used for summarizing the effect estimates.

RESULTS

Forty-three reports were selected, having sampled 153,372 Africans from 26 countries. Education was the most frequent SES indicator and composite measures of sleep quality or disturbances was the most common sleep outcome. Low educational attainment was significantly associated with lower odds of short sleep (odds ratio [OR]=0.65, 95% confidence intervals [0.50, 0.84], p = .001) and higher odds of insomnia (OR=1.53, [1.18, 1.99], p = .001) or poor sleep quality (OR=1.60, [1.17, 2.18], p = .003). Low levels of income/assets were related to higher odds of insomnia (OR=1.38, [1.02, 1.86], p = .04) and low occupational/employment status was linked to lower odds of short sleep duration (OR=0.49, [0.30, 0.79], p = .004).

CONCLUSIONS

Socioeconomic disadvantage was a significant predictor of insomnia and poor sleep quality, while it was associated with longer sleep duration. Significant heterogeneity in terms of exposure and outcomes, scarcity of longitudinal designs, lack of objective outcome measurement, and low representation of rural samples and participants from low-income countries limit the quality of evidence.

Associations of race and socioeconomic status with outcomes after intracranial meningioma resection: a systematic review and meta-analysis

PURPOSE

Social determinants of health broadly affect healthcare access and outcomes. Studies report that minorities and low socioeconomic status (SES) patients undergoing intracranial meningioma resection demonstrate worse outcomes and higher mortality rates. This systematic review and meta-analysis summarizes the available research reporting racial and SES disparities in intracranial meningioma resection outcomes.

METHODS

A systematic review was conducted using PRISMA guidelines and included peer-reviewed, English-language articles from the United States between 2000 and 2022 that reported racial and SES disparities in meningioma outcomes. Outcomes included overall survival (OS), extent of resection (EOR), hospitalization costs, length of stay (LOS), 30-day readmission, recurrence, and receipt of surgery and adjuvant radiotherapy. A quantitative meta-analysis was performed only on survival outcomes by race. All other variables were summarized as a systematic review.

RESULTS

633 articles were identified; 19 studies met inclusion criteria. Black or low SES patients were more likely to have increased hospitalization costs, rates of 30-day readmission, LOS, recurrence and less likely to undergo surgery, gross total resection, and adjuvant radiotherapy for their tumors. Six studies were used for the quantitative meta-analysis of race and OS. Compared to White patients, Black patients had significantly worse survival outcomes, and Asian patients had significantly better survival outcomes.

CONCLUSION

Disparities in outcomes exist for patients who undergo surgery for meningioma, such that Black and low SES patients have worse outcomes. The literature is quite sparse and contains confounding relationships not often accounted for appropriately. Further studies are needed to help understand these disparities to improve outcomes.

Trends in Leadership Among Neurosurgical Oncology Fellowships

OBJECTIVE

To examine current neurosurgical oncology leadership trends and provide a guide for those interested in obtaining fellowship directorship, we investigated fellowship director (FD) demographic, educational, and leadership characteristics.

METHODS

The American Association of Neurological Surgeons Academic Fellowship Directory and Committee on Advanced Subspecialty Training websites were reviewed for current U.S. program FDs for which data were collected using online resources and surveys.

RESULTS

In total, 23 FDs (20 male and 3 female) were represented whose mean age was 52.4 years (standard deviation = 8.7). Our analysis found 65% of current neurosurgical oncology FDs to be singularly trained in neurosurgical oncology, with 8.7% possessing multiple fellowships and 34.8% possessing additional degrees. Fellowship programs producing the most FDs were University of Texas MD Anderson (4), Memorial Sloan Kettering (3), and University of Miami (2). FDs possessed an average of 148 publications, 6423 citations, and an h-index of 33.9. H-index had a high-positive correlation with age and time from residency graduation but not duration of FD appointment. Among survey respondents, 91.7% reported membership and 75% reported leadership positions among national academic societies, whereas 66.7% reported holding journal-editorial positions. The mean age of FD appointment was 46.8 years, with a mean time from fellowship completion to FD appointment of 10.0 years.

CONCLUSIONS

Through the characterization of current leaders in the field, we provide valuable information with regards to training location trends, research productivity goals, career timelines, and target journal/national academic society involvement worth consideration among young trainees when making career decisions and plans.

Do the indices of deprivation or smoking affect post-operative 1-year mortality in patients undergoing a craniotomy for a brain tumour in a public healthcare system?

OBJECTIVE

We sought to determine the 1-year survival following craniotomy for tumour resection in a public healthcare system and analyse the effect of indices of multiple deprivation (IMD) as well as smoking, alcohol, BMI, ASA grade and medical co-morbidities on post-operative morbidity and mortality.

METHODS

This is a retrospective, single-centre study in a high volume neurosurgical centre, over a 2-year period. All patients undergoing a craniotomy for a brain tumour were included. Data was collected from the neuro-oncology database and electronic patient records. Individual patient IMD data was obtained using their postcode from a national government database. Each English postcode being ranked from 1 to 32,844, with 1 being the most deprived and 32,844 the most affluent. Descriptive results are described along with further data analysis using multiple linear and logistic regression analyses.

RESULTS

630 patients underwent an elective or urgent craniotomy for tumour. 10% of all patients underwent urgent surgery. 68% (95% CI: 64 to 71%) survived at least 1-year post-surgery. Our study found that social deprivation (IMD postcode rank) was not associated with mortality at 1 year after adjusting for potential confounding factors. Those from decile 1 had the lowest risk of death at 12 months for all tumour types (p = 0.0070). Previous smokers carried an increased risk of death at 12 months when compared with people who had never smoked RR 1.40 CI 1.10-1.78 (p = 0.006) but this risk was not evident in current smokers RR 0.92 CI 0.65-1.31 (p = 0.64). Increasing age and male gender were also found to be associated with higher mortality at 1 year (p =  < 0.001).

CONCLUSIONS

In the UK despite the discrepancy in the health of the general population between the north and south, social deprivation does not appear to be detrimental to neurooncological outcomes although smoking status, advancing age and male sex are.

Prognostic Factors and Treatment Impact on Overall Survival in Adult Craniopharyngioma

OBJECTIVE

To examine the demographics, tumor characteristics, treatments, and clinical outcomes of a large adult craniopharyngioma population.

METHODS

The 2004-2018 National Cancer Database was queried to investigate adult patients with craniopharyngioma. Univariable and multivariable Cox hazard ratio analysis was conducted to analyze the overall survival (OS) impact of demographic and clinical variables.

RESULTS

A total of 666 adult patients with craniopharyngioma were identified with a mean age of 51 years (standard deviation 16 years). On multivariable analysis, independent of demographic and clinical variables, increased age, uninsured status, Medicaid, Medicare, Charlson-Deyo Comorbidity Index of 2, and tumor size greater than 40 mm were independently associated with worse OS. There was no significant difference in survival between histologic subtypes. Gross total resection (GTR) (hazard ratio [HR] 0.602, 95% confidence interval [CI] 0.384-0.942, P = 0.026) and subtotal resection (STR) with adjuvant radiotherapy (HR 0.316, 95% CI 0.140-0.710, P = 0.005) were independently associated with improved OS. GTR with radiotherapy trended towards improved OS (HR 0.601, 95% CI 0.334-1.083, P =0.090), but STR alone and radiotherapy alone demonstrated no significant difference in survival compared with no treatment on multivariable analysis. Kaplan-Meier survival models demonstrated improved survival with GTR, GTR + radiation therapy, and STR + radiation therapy. Patients undergoing endoscopic resection had significantly lower GTR rates and greater rates of adjuvant radiotherapy compared with open approaches but no difference in OS.

CONCLUSION

Adult patients with craniopharyngioma who underwent GTR or STR with adjuvant radiotherapy had significantly improved overall survival. Endoscopic approaches had lower rates of GTR but no difference in OS.

Challenges and Opportunities for Clinical Trials in Patients With Glioma

This Viewpoint discusses the challenges and opportunities of including patients with glioma in clinical trials.

Racial disparities in inpatient clinical presentation, treatment, and outcomes in brain metastasis

Background

Few studies have assessed the impact of race on short-term patient outcomes in the brain metastasis population. The goal of this study is to evaluate the association of race with inpatient clinical presentation, treatment, in-hospital complications, and in-hospital mortality rates for patients with brain metastases (BM).

Method

Using data collected from the National Inpatient Sample between 2004 and 2014, we retrospectively identified adult patients with a primary diagnosis of BM. Outcomes included nonroutine discharge, prolonged length of stay (pLOS), in-hospital complications, and mortality.

Results

Minority (Black, Hispanic/other) patients were less likely to receive surgical intervention compared to White patients (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.66-0.74, p < 0.001; OR 0.88; 95% CI 0.84-0.93, p < 0.001). Black patients were more likely to develop an in-hospital complication than White patients (OR 1.35, 95% CI 1.28-1.41, p < 0.001). Additionally, minority patients were more likely to experience pLOS than White patients (OR 1.48; 95% CI 1.41-1.57, p < 0.001; OR 1.34; 95% CI 1.27-1.42, p < 0.001). Black patients were more likely to experience a nonroutine discharge (OR 1.25; 95% CI 1.19-1.31, p < 0.001) and higher in-hospital mortality than White (OR 1.13; 95% CI 1.03-1.23, p = 0.008).

Conclusion

Our analysis demonstrated that race is associated with disparate short-term outcomes in patients with BM. More efforts are needed to address these disparities, provide equitable care, and allow for similar outcomes regardless of care.

Meningioma classification by immunohistochemistry: A replicability study

Introduction

Meningiomas account for nearly 40% of intracranial tumors. Recently, the immunohistochemistry (IHC) markers S100B, SCGN, ACADL and MCM2 have been shown to be associated with underlying biological subtypes of meningioma (MG1-MG4). We aimed to evaluate these IHC markers in a clinical setting.

Research question

Are the new proposed IHC markers clinically useful?

Methods

In total, 244 patients with meningiomas with tissue in TMAs were included and the IHC markers S100B, SCGN, ACADL and MCM2 were analyzed. Two sets of analyses were performed; the first included all samples with any staining considered positive, the second only samples with >10% immunopositivity. PFS and OS were analyzed in correlation to immunopositivity in the second analysis set.

Results

In the first set of analyses only 26.2% of samples could be to allocate to one group. No further analyses were performed with this selection. In the second set of analyses 52.0% could be allocated to a group. There was an enrichment of WHO grade 2 and 3 tumors in MG3 and MG4 as compared to MG1 (24.1% and 25.7% vs. 12.1%). Both the molecular group (p ​= ​0.032) and WHO grade (p ​= ​0.005) had significant impact on PFS, but only WHO grade predicted OS (p ​= ​0.033).

Conclusion

We studied the proposed new method of classifying meningiomas into groups MG1, MG2, MG3 and MG4 using IHC markers, but found difficulties applying the classification system in our material mainly due to lack of exclusivity of markers. Thus, in its present form the classification method lacks clinical applicability.

Racial disparities in recommendations for surgical resection of primary brain tumours: a registry-based cohort analysis

BACKGROUND

Disparities in treatment and outcomes disproportionately affect minority ethnic and racial populations in many surgical fields. Although substantial research in racial disparities has focused on outcomes, little is known about how surgeon recommendations can be influenced by patient race. The aim of this study was to investigate racial and socioeconomic disparities in the surgical management of primary brain tumors.

METHODS

In this registry-based cohort study, we used data from the Surveillance, Epidemiology, and End Results (SEER) database (1975-2016) and the American College of Surgeons National Cancer Database (NCDB) in the USA for independent analysis. Adults (aged ≥20 years) with a new diagnosis of meningioma, glioblastoma, pituitary adenoma, vestibular schwannoma, astrocytoma, and oligodendroglioma, with information on tumour size and surgical recommendation were included in the analysis. The primary outcome of this study was the odds of a surgeon recommending against surgical resection at diagnosis of primary brain neoplasms. This outcome was determined using multivariable logistic regression with clinical, demographic, and socioeconomic factors.

FINDINGS

This study included US national data from the SEER (1975-2016) and NCDB (2004-17) databases of adults with a new diagnosis of meningioma (SEER n=63 674; NCDB n=222 673), glioblastoma (n=35 258; n=104 047), pituitary adenoma (n=27 506; n=87 772), vestibular schwannoma (n=11 525; n=30 745), astrocytoma (n=5402; n=10 631), and oligodendroglioma (n=3977; n=9187). Independent of clinical and demographic factors, including insurance status and rural-urban continuum code, Black patients had significantly higher odds of recommendation against surgical resection of meningioma (adjusted odds ratio 1·13, 95% CI 1·06-1·21, p<0·0001), glioblastoma (1·14, 1·01-1·28, p=0·038), pituitary adenoma (1·13, 1·05-1·22, p<0·0001), and vestibular schwannoma (1·48, 1·19-1·84, p<0·0001) when compared with White patients in the SEER dataset. Additionally, patients of unknown race had significantly higher odds of recommendation against surgical resection for pituitary adenoma (1·80, 1·41-2·30, p<0·0001) and vestibular schwannoma (1·49, 1·10-2·04, p=0·011). Performing a validation analysis using the NCDB dataset confirmed these significant results for Black patients with meningioma (1·18, 1·14-1·22, p<0·0001), glioblastoma (1·19, 1·12-1·28, p<0·0001), pituitary adenoma (1·21, 1·16-1·25, p<0·0001), and vestibular schwannoma (1·19, 1·04-1·35, p=0·0085), and indicated and indicated that the findings are independent of patient comorbidities. When further restricted to the most recent decade in SEER, these inequities held true for Black patients, except those with glioblastoma (meningioma [1·18, 1·08-1·28, p<0·0001], pituitary adenoma [1·20, 1·09-1·31, p<0·0001], and vestibular schwannoma [1·54, 1·16-2·04, p=0·0031]).

INTERPRETATION

Racial disparities in surgery recommendations in the USA exist for patients with primary brain tumours, independent of potential confounders including clinical, demographic, and select socioeconomic factors. Further studies are needed to understand drivers of this bias and enhance equality in surgical care.

FUNDING

None.

Federated learning enables big data for rare cancer boundary detection

Although machine learning (ML) has shown promise across disciplines, out-of-sample generalizability is concerning. This is currently addressed by sharing multi-site data, but such centralization is challenging/infeasible to scale due to various limitations. Federated ML (FL) provides an alternative paradigm for accurate and generalizable ML, by only sharing numerical model updates. Here we present the largest FL study to-date, involving data from 71 sites across 6 continents, to generate an automatic tumor boundary detector for the rare disease of glioblastoma, reporting the largest such dataset in the literature (n = 6, 314). We demonstrate a 33% delineation improvement for the surgically targetable tumor, and 23% for the complete tumor extent, over a publicly trained model. We anticipate our study to: 1) enable more healthcare studies informed by large diverse data, ensuring meaningful results for rare diseases and underrepresented populations, 2) facilitate further analyses for glioblastoma by releasing our consensus model, and 3) demonstrate the FL effectiveness at such scale and task-complexity as a paradigm shift for multi-site collaborations, alleviating the need for data-sharing.

Incidence trends and survival analysis of atypical meningiomas: a population-based study from 2004 to 2018

PURPOSE

Atypical meningiomas have histologic and clinical features that fall between those for benign and malignant meningiomas. The incidence of atypical meningiomas has not been well studied with respect to changes in the World Health Organization (WHO) classification scheme over time.

METHODS

The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database was queried to obtain data from 2004 to 2018 for patients with all meningiomas, including atypical. Age-adjusted incidence rates were generated and annual percent change (APC) in the incidence rates was calculated with joinpoint regression. Survival was analyzed using the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

A total of 4476 patients diagnosed with meningioma were identified from the SEER 18 registries. The incidence of atypical meningioma increased at an APC of 5.6% [95% confidence interval [CI], 3.4-7.8]; significantly faster than all meningiomas, which rose at an APC of 2.5% (95%CI 1.8-3.1;p = 0.008). For atypical meningiomas, the 1, 3, 5, and 10-year survival rates were 91.9%, 81.3%, 68.8%, and 34.3%, respectively. Male sex, older age (≥ 60 years), and large tumor size (> 5 cm) were independent risk factors for an unfavorable prognosis.

CONCLUSIONS

The incidence of atypical meningioma was observed to be increasing relative to all meningiomas. It is important to diligently monitor atypical meningioma incidence and mortality rates over time to see whether observed uptrends persist. Continued effort toward improving outcomes in patients with atypical meningiomas is warranted, especially in light of an apparent rise in incidence.

Ethnic and socioeconomic disparities in survival of children and adolescents with CNS tumors in Southern Israel

Background

This study sought to evaluate survival of pediatric and adolescent patients with central nervous system (CNS) cancer in southern Israel, outline disparities between ethnic and socioeconomic groups (Bedouin Arabs compared to Jews) and evaluate the role of socioeconomic status (SES) in ethnic disparities.

Methods

A retrospective study was conducted among 91 patients aged one to 20 years, who were diagnosed with CNS tumors between 2001 and 2017, and followed-up through 2020. Ethnic differences in survival were measured by age, sex, stage, histology and SES. One and 3-year survival rates were calculated. Multivariable regression analysis was used to estimate adjusted ethnic differences in survival rates.

Results

Ethnic differences in survival existed within all studied variables. All Bedouin patients lived in low SES settlements (All Bedouin settlement in Southern Israel are ranked in lower socioeconomic deciles). Twenty-eight patients had medulloblastoma. Seven (25%) presented with leptomeningeal disease or distant metastases. Medulloblastoma molecular subgroups were not assessed for logistic reasons. Three-year overall survival of Bedouins was 50% compared to 92.3% for Jews. Adjusted risk of death at 3 years was significantly higher for Bedouin patients (aHR 3.36, 95% CI 1.41–7.98, P = .006).

Conclusions

We conclude that Bedouin children with CNS tumors have significantly lower survival rates compared to Jewish children, and SES seems to play a major part in these disparities. Factors influencing these disparities should be addressed and public health interventions to eliminate these disparities should be developed.

Association of Patient Frailty With Vestibular Schwannoma Resection Outcomes and Machine Learning Development of a Vestibular Schwannoma Risk Stratification Score

BACKGROUND

Patient frailty is predictive of higher neurosurgical morbidity and mortality. However, existing frailty measures are hindered by lack of specificity to neurosurgery.

OBJECTIVE

To analyze the association between 3 risk stratification scores and outcomes for nationwide vestibular schwannoma (VS) resection admissions and develop a custom VS risk stratification score.

METHODS

We identified all VS resection admissions in the National Inpatient Sample (2002-2017). Three risk stratification scores were analyzed: modified Frailty Index-5, modified Frailty Index-11(mFI-11), and Charlson Comorbidity Index (CCI). Survey-weighted multivariate regression evaluated associations between frailty and inpatient outcomes, adjusting for patient demographics, hospital characteristics, and disease severity. Subsequently, we used k-fold cross validation and Akaike Information Criterion-based model selection to create a custom risk stratification score.

RESULTS

We analyzed 32 465 VS resection admissions. High frailty, as identified by the mFI-11 (odds ratio [OR] = 1.27, P = .021) and CCI (OR = 1.72, P < .001), predicted higher odds of perioperative complications. All 3 scores were also associated with lower routine discharge rates and elevated length of stay (LOS) and costs (all P < .05). Our custom VS-5 score (https://skullbaseresearch.shinyapps.io/vs-5_calculator/) featured 5 variables (age ≥60 years, hydrocephalus, preoperative cranial nerve palsies, diabetes mellitus, and hypertension) and was predictive of higher mortality (OR = 6.40, P = .001), decreased routine hospital discharge (OR = 0.28, P < .001), and elevated complications (OR = 1.59, P < .001), LOS (+48%, P < .001), and costs (+23%, P = .001). The VS-5 outperformed the modified Frailty Index-5, mFI-11, and CCI in predicting routine discharge (all P < .001), including in a pseudoprospective cohort (2018-2019) of 3885 admissions.

CONCLUSION

Patient frailty predicted poorer inpatient outcomes after VS surgery. Our custom VS-5 score outperformed earlier risk stratification scores.

Association between socioeconomic status and presenting characteristics and extent of disease in patients with surgically resected nonfunctioning pituitary adenoma

OBJECTIVE

The aim of this study was to evaluate the association between zip code-level socioeconomic status (SES) and presenting characteristics and short-term clinical outcomes in patients with nonfunctioning pituitary adenoma (NFPA).

METHODS

A retrospective review of prospectively collected data from the University of Southern California Pituitary Center was conducted to identify all patients undergoing surgery for pituitary adenoma (PA) from 2000 to 2021 and included all patients with NFPA with recorded zip codes at the time of surgery. A normalized socioeconomic metric by zip code was then constructed using data from the American Community Survey estimates, which was categorized into tertiles. Multiple imputation was used for missing data, and multivariable linear and logistic regression models were constructed to estimate mean differences and multivariable-adjusted odds ratios for the association between zip code-level SES and presenting characteristics and outcomes.

RESULTS

A total of 637 patients were included in the overall analysis. Compared with patients in the lowest SES tertile, those in the highest tertile were more likely to be treated at a private (rather than safety net) hospital, and were less likely to present with headache, vision loss, and apoplexy. After multivariable adjustment for age, sex, and prior surgery, SES in the highest compared with lowest tertile was inversely associated with tumor size at diagnosis (-4.9 mm, 95% CI -7.2 to -2.6 mm, p < 0.001) and was positively associated with incidental diagnosis (multivariable-adjusted OR 1.72, 95% CI 1.02-2.91). Adjustment for hospital (private vs safety net) attenuated the observed associations, but disparities by SES remained statistically significant for tumor size. Despite substantial differences at presentation, there were no significant differences in length of stay or odds of an uncomplicated procedure by zip code-level SES. Patients from lower-SES zip codes were more likely to require postoperative steroid replacement and less likely to achieve gross-total resection.

CONCLUSIONS

In this series, lower zip code-level SES was associated with more severe disease at the time of diagnosis for NFPA patients, including larger tumor size and lower rates of incidental diagnosis. Despite these differences at presentation, no significant differences were observed in short-term postoperative complications, although patients with higher zip code-level SES had higher rates of gross-total resection.

The Discrepancy Between Standard Histologic WHO Grading of Meningioma and Molecular Profile: A Single Institution Series

Introduction

Meningiomas are the most common primary central nervous system (CNS) tumor. They are most often benign, but a subset of these can behave aggressively. Current World Health Organization (WHO) guidelines classify meningiomas into three grades based on the histologic findings and presence or absence of brain invasion. These grades are intended to guide treatment, but meningiomas can behave inconsistently with regard to their assigned histopathological grade, influencing patient expectations and management. Advanced molecular profiling of meningiomas has led to the proposal of alternative molecular grading schemes that have shown superior predictive power. These include methylation patterns, copy number alterations, and mutually exclusive driver mutations affecting oncogenes, including BAP1, CDKN2A/B, and the TERT promoter, which are associated with particularly aggressive tumor biology. Despite the evident clinical value, advanced molecular profiling methods are not widely incorporated in routine clinical practice for meningiomas.

Objective

To assess the degree of concordance between the molecular profile of meningiomas and the histopathologic WHO classification, the current method of predicting meningioma behavior.

Methods

In a two-year single-institution experience, we used commercially available resources to determine molecular profiles of all resected meningiomas. Copy number aberrations and oncogenic driver mutations were identified and compared with the histopathologic grade.

Results

One hundred fifty-one total meningioma cases were included for analysis (85.4% WHO grade 1, 13.3% WHO grade 2, and 1.3% grade 3). Chromosomal analysis of 124 of these samples showed that 29% of WHO grade 1 tumor featured copy number profiles consistent with higher grade meningioma, and 25% of WHO grade 2 meningiomas had copy number profiles consistent with less aggressive tumors. Furthermore, 8% harbored mutations in TERT, CDKN2A/B, or BAP1 of which 6% occurred in grade 1 meningiomas.

Conclusions

Routine advanced molecular profiling of all resected meningiomas using commercially available resources allowed for identification of a significant number of meningiomas whose molecular profiles were inconsistent with WHO grade. Our work shows the clinical value of integrating routine molecular profiling with histopathologic grading to guide clinical decision making.

Socioeconomic Disparities in Brain Metastasis Survival and Treatment: A Population-Based Study

OBJECTIVE

In the present study, we used a validated socioeconomic status (SES) index and population-based registry to identify and quantify the impact of SES on access to treatment and overall survival for patients diagnosed with synchronous brain metastases.

METHODS

The Surveillance, Epidemiology, and End Results database was used to extract all patients between 2010 and 2016 with brain metastases at initial presentation. SES was stratified into tertiles and quintiles using the validated Yost index. Multivariable logistic regressions were used to evaluate the impact of demographic, tumor, and socioeconomic covariates on receipt of radiotherapy and chemotherapy. Kaplan-Meier curves were used to estimate survival.

RESULTS

Between 2010 and 2016, 35,595 patients presented with brain metastases at the time of primary cancer diagnosis. Most patients received radiation and/or chemotherapy as part of the initial course of their treatment; 71.6% (n = 25,484) were irradiated while 54.4% (n = 19,371) received chemotherapy and 44.9% (n = 15,984) received chemoradiation. Patients in the highest Yost tertile and quintile experienced longer overall survival (P < 0.001). Additionally, multivariable logistic regression revealed that the lowest Yost quintile was significantly less likely to receive either radiation (adjusted OR: 0.82; 95% confidence interval: 0.75-0.89; P < 0.001) or chemotherapy (adjusted OR: 0.62; 95% confidence interval: 0.58-0.67; P < 0.001).

CONCLUSIONS

In a large, population-based analysis of brain metastasis patients, we found significant differences in treatment access and mild survival differences along socioeconomic strata. More specifically, patients in lower SES tiers suffered worse outcomes and received radiation and chemotherapy less frequently than patients in higher tiers, even after accounting for other tumor- and demographic-related information.

Disparities in Reported Testing for 1p/19q Codeletion in Oligodendroglioma and Oligoastrocytoma Patients: An Analysis of the National Cancer Database

Purpose

A chromosomal 1p/19q codeletion was included as a required diagnostic component of oligodendrogliomas in the 2016 World Health Organization (WHO) classification of central nervous system tumors. We sought to evaluate disparities in reported testing for 1p/19q codeletion among oligodendroglioma and oligoastrocytoma patients before and after the guidelines.

Methods

The National Cancer Database (NCDB) was queried for patients with histologically-confirmed WHO grade II/III oligodendroglioma or oligoastrocytoma from 2011-2017. Adjusted odds of having a reported 1p/19q codeletion test for patient- and hospital-level factors were calculated before (2011-2015) and after (2017) the guidelines. The adjusted likelihood of receiving adjuvant treatment (chemotherapy and/or radiotherapy) based on reported testing was also evaluated.

Results

Overall, 6,404 patients were identified. The reported 1p/19q codeletion testing rate increased from 45.8% in 2011 to 59.8% in 2017. From 2011-2015, lack of insurance (OR 0.77; 95% CI 0.62-0.97;p=0.025), lower zip code-level educational attainment (OR 0.62; 95% CI 0.49-0.78;p<0.001), and Northeast (OR 0.68; 95% CI 0.57-0.82;p<0.001) or Southern (OR 0.62; 95% CI 0.49-0.79;p<0.001) facility geographic region were negatively associated with reported testing. In 2017, Black race (OR 0.49; 95% CI 0.26-0.91;p=0.024) and Northeast (OR 0.50; 95% CI 0.30-0.84;p=0.009) or Southern (OR 0.42; 95% CI 0.22-0.78;p=0.007) region were negatively associated with reported testing. Patients with a reported test were more likely to receive adjuvant treatment (OR 1.73; 95% CI 1.46-2.04;p<0.001).

Conclusion

Despite the 2016 WHO guidelines, disparities in reported 1p/19q codeletion testing by geographic region persisted while new disparities in race/ethnicity were identified, which may influence oligodendroglioma and oligoastrocytoma patient management.

Neighborhood Socioeconomic Deprivation and Mortality in Children with Central Nervous System Tumors

BACKGROUND

Although there is evidence of socioeconomic disparities in survival of children diagnosed with central nervous system (CNS) tumors, the impact of neighborhood socioeconomic deprivation on the survival of these malignancies has not been adequately studied. We investigated the association between area deprivation index (ADI), a measure of neighborhood socioeconomic disadvantage, and pediatric CNS tumor survival.

METHODS

Demographic and clinical characteristics, geocoded addresses at diagnosis, and vital status of pediatric CNS tumor cases (n = 5,477) for the period 1995 to 2017 were obtained from the Texas Cancer Registry. ADI scores were computed for census tracts in Texas using the U.S. Census Bureau 2010 geography. Tracts were classified into quartiles as least, third-most, second-most, and most disadvantaged. Children were mapped to quartiles based on residency at diagnosis. The adjusted hazard ratio (HR) and 95% confidence interval (CI) were calculated.

RESULTS

The results showed a significantly increased HR for death among children in the most (HR, 1.29; 95% CI, 1.09-1.51), second-most (HR, 1.18; 95% CI, 1.01-1.38), and third-most disadvantaged census tracts (HR, 1.18; 95% CI, 1.02-1.37) compared with children in the least disadvantaged tracts.

CONCLUSIONS

Children living in the most disadvantaged neighborhoods experienced a significantly higher risk of mortality, indicating the important role of socioeconomic disparities in the survival of pediatric CNS tumors.

IMPACT

The demographic and socioeconomic disparities identified by this study should be considered when planning treatment strategies for these susceptible groups and thus, lead to a better outcome in socioeconomically disadvantaged children diagnosed with CNS tumors.

A Molecularly Integrated Grade for Meningioma

Background

Meningiomas are the most common primary intracranial tumor in adults. Clinical care is currently guided by the World Health Organization (WHO) grade assigned to meningiomas, a 3-tiered grading system based on histopathology features, as well as extent of surgical resection. Clinical behavior, however, often fails to conform to the WHO grade. Additional prognostic information is needed to optimize patient management.

Methods

We evaluated whether chromosomal copy-number data improved prediction of time-to-recurrence for patients with meningioma who were treated with surgery, relative to the WHO schema. The models were developed using Cox proportional hazards, random survival forest, and gradient boosting in a discovery cohort of 527 meningioma patients and validated in 2 independent cohorts of 172 meningioma patients characterized by orthogonal genomic platforms.

Results

We developed a 3-tiered grading scheme (Integrated Grades 1-3), which incorporated mitotic count and loss of chromosome 1p, 3p, 4, 6, 10, 14q, 18, 19, or CDKN2A. 32% of meningiomas reclassified to either a lower-risk or higher-risk Integrated Grade compared to their assigned WHO grade. The Integrated Grade more accurately identified meningioma patients at risk for recurrence, relative to the WHO grade, as determined by time-dependent area under the curve, average precision, and the Brier score.

Conclusion

We propose a molecularly integrated grading scheme for meningiomas that significantly improves upon the current WHO grading system in prediction of progression-free survival. This framework can be broadly adopted by clinicians with relative ease using widely available genomic technologies and presents an advance in the care of meningioma patients.

Maternal and perinatal factors are associated with risk of pediatric central nervous system tumors and poorer survival after diagnosis

Central nervous system (CNS) tumors are the most common solid tumors in children. Findings on the role of maternal and perinatal factors on the susceptibility or outcome of these tumors are inconclusive. Therefore, we investigated the association between these early-life factors, risk, and survival of pediatric CNS tumors, using data from one of the world’s largest and most diverse cancer registries. Information on pediatric CNS tumor cases (n = 1950) for the period 1995–2011 was obtained from the Texas Cancer Registry. Birth certificate controls were frequency-matched on birth year at a ratio of 10:1 for the same period. Evaluated maternal and perinatal variables were obtained from birth records. Unconditional logistic regression was used to generate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for etiological factors. Additionally, Cox proportional hazards regression was employed to assess adjusted hazard ratios (HRs) and 95% CIs for survival factors. The results indicated that Hispanic and non-Hispanic black mothers were less likely to have children with CNS tumors compared to non-Hispanic white mothers (OR 0.88 [95% CI 0.78–0.98] P-value = 0.019; OR 0.79 [95% CI 0.67–0.93 P-value = 0.004], respectively). Infants born large for gestational age (OR 1.26 [95% CI 1.07–1.47] P-value = 0.004) and those delivered pre-term (OR 1.19 [95% CI 1.04–1.38] P-value = 0.013) showed an increased risk of CNS tumors. Infants born by vaginal forceps or vacuum delivery had a higher risk of CNS tumors compared to those born by spontaneous vaginal delivery (OR 1.35 [95% CI 1.12–1.62] P-value = 0.002). Additionally, offspring of Hispanic and non-Hispanic black mothers showed a higher risk of death (HR 1.45 [95% CI 1.16–1.80] P-value = 0.001; HR 1.53 [95% CI 1.12–2.09] P-value = 0.008, respectively). Infants born by cesarean had a higher risk of death compared to those delivered vaginally (HR 1.28 [95% CI 1.05–1.57] P-value = 0.016). These findings indicate the important role of maternal and perinatal characteristics in the etiology and survival of these clinically significant malignancies.

Disparities in the Geographic Distribution of Neurosurgeons in the United States: A Geospatial Analysis

OBJECTIVE

Large disparities in access to neurosurgical care are known, but there are limited data on whether geographic distribution of the neurosurgery workforce potentially plays a role in these disparities. The goal of this study was to identify the geographic distribution of neurosurgeons in the United States and to study the association of the per capita workforce distribution with socioeconomic characteristics of the population.

METHODS

The number of practicing neurosurgeons in the United States in 2016 was obtained from the 2017-2018 American Medical Association Masterfile contained within the Area Health Resource File. The association of the number of neurosurgeons per 100,000 population with socioeconomic characteristics was assessed through linear regression analysis at Hospital Referral Region (HRR) level.

RESULTS

The median number of neurosurgeons per capita across all HRRs was 1.47 neurosurgeons per 100,000 population (interquartile range, 1.02-2.27). Bivariable analysis showed that greater supply of neurosurgeons was positively associated with regional levels of college education, median income, and median age. The number of neurosurgeons per capita at the HRR level was negatively associated with unemployment, poverty, and percent uninsured.

CONCLUSIONS

Regions characterized by low socioeconomic status have fewer neurosurgeons per capita in the United States. Low income, low number of college graduates, and high unemployment rate are associated with fewer numbers of neurosurgeons per capita. Further research is needed to determine if these geographic workforce disparities contribute to poor access to quality neurosurgical care.

Racial and ethnic disparities among children with primary central nervous system tumors in the US

INTRODUCTION

Primary central nervous system (CNS) tumors are among the most common and lethal types of cancer in children. However, the existence of health disparities in CNS tumors by race or ethnicity remains poorly understood. This systematic review sought to determine whether racial and ethnic disparities in incidence, healthcare access, and survival exist among pediatric patients diagnosed with CNS tumors.

METHODS

A search of MEDLINE, Embase, CINAHL, Web of Science, and Scopus was conducted. Inclusion criteria selected for studies published between January 1, 2005 and July 15, 2020 that focused on pediatric populations in the US, evaluated for potential differences based on racial or ethnic backgrounds, and focused on CNS tumors. A standardized study form was used to collect study information, population of interest, research design, and quality of analysis, sample size, participant demographics, pathology evaluated, and incidence or outcomes observed.

RESULTS

A total of 30 studies were inlcuded. Studies suggest White children may be more likely to be diagnosed with a CNS tumor and Hispanic children to present with advanced-stage disease and have worse outcomes. The degree of influence derived from socioeconomic factors is unclear. This review was limited by few available studies that included race and ethnicity as a variable, the overlap in databases used, and unclear categorization of race and ethnicity.

CONCLUSIONS

This review identified notable and at times contradicting variations in racial/ethnic disparities among children with CNS tumors, suggesting that the extent of these disparities remains largely unknown and prompts further research to improve health equity.

Comparative preoperative characteristics and postoperative outcomes at a private versus a safety-net hospital following endoscopic endonasal transsphenoidal resection of pituitary adenomas

OBJECTIVE

Sociodemographic disparities in health outcomes are well documented, but the effects of such disparities on preoperative presentation of pituitary adenomas (PA) and surgical outcomes following resection are not completely understood. In this study the authors sought to compare the preoperative clinical characteristics and postoperative outcomes in patients undergoing PA resection at a private hospital (PH) versus a safety-net hospital (SNH).

METHODS

The authors conducted a retrospective review over a 36-month period of patients with PAs who underwent endoscopic endonasal transsphenoidal surgery performed by the same attending neurosurgeon at either a PH or an SNH at a single academic medical institution.

RESULTS

A total of 92 PH patients and 69 SNH patients were included. SNH patients were more likely to be uninsured or have Medicaid (88.4% vs 10.9%, p < 0.0001). A larger percentage of SNH patients were Hispanic (98.7% vs 32.6% p < 0.0001), while PH patients were more likely to be non-Hispanic white (39.1% vs 4.3%, p < 0.0001). SNH patients had a larger mean PA diameter (26.2 vs 22.4 mm, p = 0.0347) and a higher rate of bilateral cavernous sinus invasion (13% vs 4.3%, p = 0.0451). SNH patients were more likely to present with headache (68.1% vs 45.7%, p = 0.0048), vision loss (63.8% vs 35.9%, p < 0.0005), panhypopituitarism (18.8% vs 4.3%, p = 0.0031), and pituitary apoplexy (18.8% vs 7.6%, p = 0.0334). Compared to PH patients, SNH patients were as likely to undergo gross-total resection (73.9% vs 76.1%, p = 0.7499) and had similar rates of postoperative improvement in headache (80% vs 89%, p = 0.14) and vision (82% vs 84%, p = 0.74), but had higher rates of postoperative panhypopituitarism (23% vs 10%, p = 0.04) driven by preoperative endocrinopathies. Although there were no differences in tumor recurrence or progression, loss to follow-up was seen in 7.6% of PH versus 18.6% (p = 0.04) of SNH patients.

CONCLUSIONS

Patients presenting to the SNH were more often uninsured or on Medicaid and presented with larger, more advanced pituitary tumors. SNH patients were more likely to present with headaches, vision loss, and apoplexy, likely translating to greater improvements in headache and vision observed after surgery. These findings highlight the association between medically underserved populations and more advanced disease states at presentation, and underscore the likely role of academic tertiary multidisciplinary care teams and endoscopic PA resection in somewhat mitigating sociodemographic factors known to portend poorer outcomes, though longer-term follow-up is needed to confirm these findings.

Inpatient palliative care utilization for patients with brain metastases

Introduction

Given the high symptom burden and complex clinical decision making associated with a diagnosis of brain metastases (BM), specialty palliative care (PC) can meaningfully improve patient quality of life. However, no prior study has formally evaluated patient-specific factors associated with PC consultation among BM patients.

Methods

We examined the rates of PC consults in a cohort of 1303 patients with BM admitted to three tertiary medical centers from October 2015 to December 2018. Patient demographics, surgical status, 30-day readmission, and death data were collected via retrospective chart review. PC utilization was assessed by identifying encounters for which an inpatient consult to PC was placed. Statistical analyses were performed to compare characteristics and outcomes between patients who did and did not receive PC consults.

Results

We analyzed 1303 patients admitted to the hospital with BM. The average overall rate of inpatient PC consultation was 19.6%. Rates of PC utilization differed significantly by patient race (17.5% in White/Caucasian vs 26.0% in Black/African American patients, P = .0014). Patients who received surgery during their admission had significantly lower rates of PC consultation (3.9% vs 22.4%, P < .0001). Patients who either died during their admission or were discharged to hospice had significantly higher rates of PC than those who were discharged home or to rehabilitation (P < .0001).

Conclusions

In our dataset, PC consultation rates varied by patient demographic, surgical status, discharging service, and practice setting. Further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.

Racial and ethnic disparities in survival of children with brain and central nervous tumors in the United States

BACKGROUND

Despite improvements in overall survival for pediatric cancers, treatment disparities remain for racial/ethnic minorities compared to non-Hispanic Whites; however, the impact of race on treatment outcomes for pediatric brain and central nervous system (CNS) tumors in the United States is not well known.

METHODS

We included 8713 children aged 0-19 years with newly diagnosed primary brain and CNS tumors between 2000 and 2015 from the Census Tract-level SES and Rurality Database developed by Surveillance, Epidemiology, and End Results (SEER) Program. We used chi-square tests to assess differences in sociodemographic, cancer, and treatment characteristics by race/ethnicity and Kaplan-Meier curves and Cox proportional hazards models to examine differences in 10-year survival, adjusting for these characteristics.

RESULTS

Among 8713 patients, 56.75% were non-Hispanic White, 9.59% non-Hispanic Black, 25.46% Hispanic, and 8.19% from "other" racial/ethnic groups. Median unadjusted survival for all pediatric brain tumors was 53 months, but varied significantly by race/ethnicity with a median survival of 62 months for non-Hispanic Whites, 41 months for non-Hispanic Blacks, and 40 months for Hispanic and other. Multivariable analyses demonstrated minority racial groups still had significantly higher hazard of death than non-Hispanic Whites; Hispanic (adjusted hazard ratio [aHR] 1.25 [1.18-1.31]); non-Hispanic Black (aHR 1.12 [1.04-1.21]); other (aHR 1.22 [1.12-1.32]). Results were consistent when stratified by tumor histology.

CONCLUSION

We identified disparities in survival among racial/ethnic minorities with pediatric brain and CNS tumors, with Hispanic patients having the highest risk of mortality. Eliminating these disparities requires commitment toward promoting heath equity and personalized cancer treatment.

Delayed Cerebrospinal Fluid Rhinorrhea Associated With Ethmoidal Encephalocele After Resection of Remote Meningioma

Diagnosis and treatment of neurosurgical pathology present unique challenges in underserved areas, and many conditions may go undiagnosed, misdiagnosed, or untreated for prolonged periods. The development of an unusual complication, seemingly unrelated to an area of neurosurgical intervention, may be particularly perplexing to non-neurosurgical providers, particularly in areas where neurosurgical procedures have not historically been available. A 44-year-old male presented with a giant meningioma which was successfully resected. A nasal encephalocele was noted preoperatively but was not addressed due to lack of associated symptoms and distance from the tumor. The patient lived on a remote island and was lost to follow-up. He developed delayed cerebral spinal fluid (CSF) rhinorrhea three months after surgery, which was diagnosed and treated by local providers as allergic rhinitis for 11 months until he presented with new-onset seizure. Imaging demonstrated descent of the lateral ventricle into the encephalocele. The encephalocele was amputated and the skull base defect was repaired successfully. The alteration of ventricular anatomy and CSF fluid dynamics following tumor resection appears to have created an environment where a non-traumatic CSF leak could develop where it had previously shown no signs of developing. It may be prudent to treat skull base defects prophylactically to prevent this type of complication, particularly in patients of remote regions where regular follow-up is difficult.

Pediatric cancer mortality and survival in the United States, 2001-2016

BACKGROUND

Although pediatric cancer mortality and survival have improved in the United States over the past 40 years, differences exist by age, race/ethnicity, cancer site, and economic status. To assess progress, this study examined recent mortality and survival data for individuals younger than 20 years.

METHODS

Age-adjusted death rates were calculated with the National Vital Statistics System for 2002-2016. Annual percent changes (APCs) and average annual percent changes (AAPCs) were calculated with joinpoint regression. Five-year relative survival was calculated on the basis of National Program of Cancer Registries data for 2001-2015. Death rates and survival were estimated overall and by sex, 5-year age group, race/ethnicity, cancer type, and county-based economic markers.

RESULTS

Death rates decreased during 2002-2016 (AAPC, -1.5), with steeper declines during 2002-2009 (APC, -2.6), and then plateaued (APC, -0.4). Leukemia and brain cancer were the most common causes of death from pediatric cancer, and brain cancer surpassed leukemia in 2011. Death rates decreased for leukemia and lymphoma but were unchanged for brain, bone, and soft-tissue cancers. From 2001-2007 to 2008-2015, survival improved from 82.0% to 85.1%. Survival was highest in both periods among females, those aged 15 to 19 years, non-Hispanic Whites, and those in counties in the top 25% by economic status. Survival improved for leukemias, lymphomas, and brain cancers but plateaued for bone and soft-tissue cancers.

CONCLUSIONS

Although overall death rates have decreased and survival has increased, differences persist by sex, age, race/ethnicity, cancer type, and economic status. Improvements in pediatric cancer outcomes may depend on improving therapies, access to care, and supportive and long-term care.

Efficacy and safety of therapies for EGFR-mutant non-small cell lung cancer with brain metastasis: an evidence-based Bayesian network pooled study of multivariable survival analyses

Preferable treatments for epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC) with brain metastasis are elusive. The study intended to estimate the relative efficacy and safety of systemic therapies. Clinical trials about therapies for EGFR-mutant, brain-metastatic NSCLC were identified. Progression-free survival (PFS) and overall survival (OS) were analysed using random effects Bayesian network meta-analyses (NMAs) on the hazard ratio (HR)-scale. Nomogram and Kaplan-Meier plots based on clinical or individual factors are displayed using data obtained from the Surveillance Epidemiology and End Results (SEER) database. Third-generation EGFR- tyrosine kinase inhibitors (EGFR-TKI) (osimertinib), EGFR-TKIs + stereotactic radiosurgery (SRS)/whole brain radiotherapy (WBRT) (gefitinib/erlotinib + SRS/WBRT), and EGFR-TKIs (erlotinib) + anti-vascular endothelial growth factor receptor (anti-VEGFR) (bevacizumab) achieved superior PFS (HR: 0.30 (0.15-0.59); HR: 0.47 (0.31-0.72); HR: 0.50 (0.21-1.21) vs. deferring SRS/WBRT) and acceptability; EGFR-TKIs + SRS/WBRT was top ranking (vs. others) for OS followed by third-generation EGFR-TKI. In the dataset cohort of 1173 brain-metastatic NSCLC patients, the 6-month, 1-year, and 3-year survival rates were 59.8%, 41.3%, and 5.6%, respectively. Race and origin, and year of diagnosis were independent predictors of OS. Survival curves showed that the OS of patients varied significantly by histology and race. Third-generation EGFR-TKI and EGFR-TKIs + SRS/WBRT are more effective and potentially acceptable for EGFR-mutant NSCLC with brain metastases balancing OS and PFS. Surgeries without adjuvant therapies cannot significantly improve the OS of brain-metastatic NSCLC patients. The study highlights importance of osimertinib in these patients and provide a reference for clinical treatments.

Racial and socioeconomic disparities differentially affect overall and cause-specific survival in glioblastoma

INTRODUCTION

The prognostic role of racial and socioeconomic factors in patients with glioblastoma is controversially debated. We aimed to evaluate how these factors may affect survival outcomes in an overall and cause-specific manner using large, national cancer registry cohort data in the temozolomide chemoradiation era.

METHODS

The National Cancer Institute's Surveillance, Epidemiology, and End Results database was queried for patients diagnosed with glioblastoma between 2005 and 2016. Overall survival was assessed using Cox proportional hazard models using disease intrinsic and extrinsic factors. Cause-specific mortality was assessed using cumulative incidence curves and modeled using multivariate cumulative risk regression.

RESULTS

A total of 28,952 patients met the prespecified inclusion criteria and were included in this analysis. The following factors were associated with all-cause mortality: age, calendar year of diagnosis, sex, treatment receipt, tumor size, tumor location, extent of resection, median household income, and race. Asian/Pacific Islanders and Hispanic Whites had lower mortality compared to Non-Hispanic Whites. Cause-specific mortality was associated with both racial and socioeconomic groups. After adjusting for treatment and tumor-related factors, Asian/Pacific and black patients had lower glioblastoma-specific mortality. However, lower median household income and black race were associated with significantly higher non-glioblastoma mortality.

CONCLUSIONS

Despite the aggressive nature of glioblastoma, racial and socioeconomic factors influence glioblastoma-specific and non-glioblastoma associated mortality. Our study shows that patient race has an impact on glioblastoma-associated mortality independently of tumor and treatment related factors. Importantly, socioeconomic and racial differences largely contribute to non-glioblastoma mortality, including death from other cancers, cardio- and cerebrovascular events.

Racial and socioeconomic correlates of treatment and survival among patients with meningioma: a population-based study

BACKGROUND

Though meningioma is the most common primary brain tumor, there is a paucity of epidemiologic studies investigating disparities in treatment and patient outcomes. Therefore, we sought to explore how sociodemographic factors are associated with rates of gross total resection (GTR) and radiotherapy as well as survival.

METHODS

The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database was queried to identify adult patients with meningioma diagnosed between 2005 and 2015. Socioeconomic status (SES) was determined using a validated composite index in which patients were stratified into tertiles and quintiles. Multivariable logistic regression and Cox proportional hazards analyses were used to identify predictors of treatment and survival, respectively.

RESULTS

71,098 patients met our inclusion criteria. Low SES quintile was associated with reduced odds of receiving GTR (OR 0.76, 95% CI 0.69-0.83, p < 0.0001) and radiotherapy (OR 0.83, 95% CI 0.76-0.91, p < 0.0001) as well as worse survival (HR 1.48, 95% CI 1.41-1.56) as compared to the highest SES quintile. Black patients had reduced odds of GTR (OR 0.74, 95% CI 0.67-0.71, p < 0.0001) and worse survival (HR 1.23, 95% CI 1.18-1.29, p < 0.0001) as compared to white patients.

CONCLUSIONS

This national study of patients with meningioma found socioeconomic status and race to be independent inverse correlates of likelihood of GTR, radiotherapy, and survival. Limited access to care may underlie these disparities in part, and future studies are warranted to identify specific causes for these findings.

Inequalities in Meningioma Survival: Results from the National Cancer Database

Background

Meningiomas are the second most common primary tumors of the central nervous system. However, there is a paucity of literature examining how healthcare, demographic, and socioeconomic factors impact patient outcomes.

Methods

We conducted a retrospective study of 65,812 patients from the National Cancer Database (NCDB; 2004-2012) who received treatment for their meningioma. Univariate and multivariate analyses were performed with the overall five-year survival as the primary outcome, and the following factors: facility type, geography, housing area, patient insurance, sex, ethnicity, race, income, and education. The multivariate model was adjusted for patient age, co-morbidity, tumor size, behavior, and treatment strategy.

Results

Diagnosis and treatment at an academic/research program, private insurance, female sex, Hispanic ethnicity, and high school diploma conferred a survival advantage on both univariate and multivariate analyses.

Conclusions

Disparities in survival outcomes in patients with meningiomas exist across multiple healthcare, demographic, and socioeconomic factors. Additional research is needed to elucidate the genetic and environmental factors driving these inequalities.

Predictors and early survival outcomes of maximal resection in WHO grade II 1p/19q-codeleted oligodendrogliomas

BACKGROUND

Although surgery plays a crucial diagnostic role in World Health Organization (WHO) grade II 1p/19q-codeleted oligodendrogliomas, the role of maximal tumor surgical resection remains unclear, with early retrospective series limited by lack of molecular classification or appropriate control groups.

METHODS

The characteristics, management, and overall survival (OS) of patients ≥20 years old presenting with histology-proven WHO grade II 1p/19q-codeleted oligodendrogliomas during 2010-2016 were evaluated using the National Cancer Database and validated using multi-institutional data. Patients were stratified by watchful waiting (biopsy only) versus surgical resection. OS was analyzed using Kaplan-Meier methods and risk-adjusted proportional hazards.

RESULTS

Five hundred ninety adults met inclusion criteria, of whom 79.0% (n = 466) underwent surgical resection. Of patient and tumor characteristics, younger patients were more likely to be resected. Achieving gross total resection (GTR; n = 320) was significantly associated with smaller tumors, management at integrated network cancer programs (vs community cancer programs), and Medicare insurance (as compared with no, private, or Medicaid/other government insurance) and independent of other patient or tumor characteristics. In risk-adjusted analyses, GTR, but not subtotal resection (STR), demonstrated improved OS (vs biopsy only: hazard ratio 0.28, 95% CI: 0.09-0.85, P = 0.02).

CONCLUSIONS

WHO grade II 1p/19q-codeleted oligodendrogliomas amenable to resection demonstrated improved OS with GTR, but not STR, compared with biopsy-only watchful waiting. The OS benefits of GTR were independent of age, tumor size, or tumor location. Medicare-insured and integrated network cancer program patients were significantly more likely to have GTR than other patients, suggesting that insurance status and care setting may play important roles in access to timely diagnosis or innovations that improve maximal resection.

Predictors of an Extended Length of Stay following an Elective Craniotomy in Children and Young Adults

BACKGROUND

Length of stay (LOS) is now a generally accepted clinical metric within the USA. An extended LOS following an elective craniotomy can significantly impact overall costs. Few studies have evaluated predictors of an extended LOS in pediatric neurosurgical patients.

OBJECTIVE

The aim of the study was to determine predictors of an extended hospital LOS following an elective craniotomy in children and young adults.

METHODS

All pediatric patients and young adults undergoing an elective craniotomy between January 1, 2010, and April 1, 2019, were retrospectively identified using a prospectively maintained database. Demographic, clinical, radiological, and surgical data were collected. The primary outcome was extended LOS, defined as a postsurgical stay greater than 7 days. Bivariate and multivariable analyses were performed.

RESULTS

A total of 1,498 patients underwent 1,720 elective craniotomies during the study period over the course of 1,698 hospitalizations with a median LOS of 4 days (interquartile range 3-6 days). Of these encounters, 218 (12.8%) had a prolonged LOS. Multivariable analysis demonstrated that non-Caucasian race (OR = 1.9 [African American]; OR = 1.6 [other]), the presence of an existing shunt (OR = 1.8), the type of craniotomy (OR = 0.3 [vascular relative to Chiari]), and the presence of a postoperative complication (OR = 14.7) were associated with an extended LOS.

CONCLUSIONS

Inherent and modifiable factors predict a hospital stay of more than a week in children and young adults undergoing an elective craniotomy.

Racial/ethnic and socioeconomic survival disparities for children and adolescents with central nervous system tumours in the United States, 2000-2015

BACKGROUND AND OBJECTIVES

Central nervous system (CNS) malignancy is the commonest cause of cancer death in children and adolescents (0-19 years) in high-income settings. There is limited data on survival inequalities by race/ethnicity and socioeconomic position (SEP), for young patients, we aim to analyse their influence on survival from childhood CNS tumour.

METHODS

9577 children and adolescents diagnosed with primary malignant CNS tumours during 2000-2015, followed up until Dec 31 st, 2015, and reported to cancer registries (Surveillance, Epidemiology and End Results programme) were included in the analysis. Cox regression models estimated the hazard ratios for race/ethnicity, SEP, and individual insurance status, adjusting for sex, age, diagnostic period, and tumour type. Individual-level insurance status data were available from 2007.

RESULTS

62.5 % children and adolescents were non-Hispanic White, 10.6 % were non-Hispanic Black and 26.9 % were Hispanic. Race/ethnicity was strongly associated with survival (p < 0.001), even after adjusting for SEP, with Black (HR = 1.39 [95 %CI 1.23-1.58]) and Hispanic children (HR = 1.40 [95 %CI 1.28-1.54]) having higher hazards of death than White children. This association remained after adjusting for insurance status. There was an apparent positive association between SEP and survival that was largely attenuated after adjustment for insurance status (p = 0.20). Survival was comparable between those privately and Medicaid-insured.

CONCLUSIONS

Non-Hispanic Black and Hispanic children had lower survival than their White counterparts. This association, not fully explained by differences in SEP, tumour subtype or health insurance, could be related to racially/ethnically-driven barriers to optimal healthcare, warranting further investigation.

Trends in intracranial meningioma incidence in the United States, 2004-2015

BACKGROUND

Meningioma incidence was reported to have risen substantially in the United States during the first decade of the 21st century. There are few reports about subsequent incidence trends. This study provides updated data to investigate trends in meningioma incidence by demographic and tumor characteristics at diagnosis in the United states from 2004 to 2015.

METHODS

Trends in meningioma incidence were analyzed using data from the Surveillance, Epidemiology, and End Results-18 (SEER-18) registry database of the National Cancer Institute. The joinpoint program was used to calculate annual percent change (APC) in incidence rates.

RESULTS

The overall incidence of meningioma increased by 4.6% (95% CI, 3.4-5.9) annually in 2004-2009, but remained stable from 2009 to 2015 (APC, 0; 95% CI, -0.8 to 0.8). Females (10.66 per 100 000 person-years) and blacks (9.52 per 100 000 person-years) had significant predominance in meningioma incidence. Incidence in many subgroups increased significantly up to 2009 and then remained stable until 2015. However, meningioma incidence in young and middle-aged people increased significantly throughout the entire time period from 2004 to 2015 (APC: 3.6% for <20-year-olds; 2.5% for 20-39-year-olds; 1.8% for 40-59-year-olds). The incidence of WHO II meningioma increased during 2011-2015 (APC = 5.4%), while the incidence of WHO III meningioma decreased during 2004-2015 (APC = -5.6%).

CONCLUSION

In this study, the incidence of meningioma was found to be stable in recent years. Possible reasons for this finding include changes in population characteristics, the widespread use of diagnostic techniques, and changes in tumor classification and risk factors in the US population.

Social determinants of health affecting treatment of pediatric brain tumors

OBJECTIVE

Little is understood about the role that health disparities play in the treatment and management of brain tumors in children. The purpose of this study was to determine if health disparities impact the timing of initial and follow-up care of patients, as well as overall survival.

METHODS

The authors conducted a retrospective study of pediatric patients (< 18 years of age) previously diagnosed with, and initially treated for, a primary CNS tumor between 2005 and 2012 at Monroe Carell Jr. Children's Hospital at Vanderbilt. Primary outcomes included time from symptom presentation to initial neurosurgery consultation and percentage of missed follow-up visits for ancillary or core services (defined as no-show visits). Core services were defined as healthcare interactions directly involved with CNS tumor management, whereas ancillary services were appointments that might be related to overall care of the patient but not directly focused on treatment of the tumor. Statistical analysis included Pearson's chi-square test, nonparametric univariable tests, and multivariable linear regression. Statistical significance was set a priori at p < 0.05.

RESULTS

The analysis included 198 patients. The median time from symptom onset to initial presentation was 30.0 days. A mean of 7.45% of all core visits were missed. When comparing African American and Caucasian patients, there was no significant difference in age at diagnosis, timing of initial symptoms, or tumor grade. African American patients missed significantly more core visits than Caucasian patients (p = 0.007); this became even more significant when controlling for other factors in the multivariable analysis (p < 0.001). African American patients were more likely to have public insurance, while Caucasian patients were more likely to have private insurance (p = 0.025). When evaluating survival, no health disparities were identified.

CONCLUSIONS

No significant health disparities were identified when evaluating the timing of presentation and survival. A racial disparity was noted when evaluating missed follow-up visits. Future work should focus on identifying reasons for differences and whether social determinants of health affect other aspects of treatment.