The impact of racial/ethnic disparities on survival for children and adolescents with extremity sarcomas: A population-based study

Socioeconomic disparities in reception of limb-sparing surgery versus amputation for lower extremity sarcoma

BACKGROUND

In lower extremity sarcoma treatment, limb salvage approaches present superior alternatives to amputation due to reduced postoperative morbidity and improved quality of life. This study provides a novel analysis of socioeconomic disparities that may affect reception of limb-sparing surgery.

METHODS

Patients with lower extremity bone or soft tissue sarcoma who received either limb-sparing surgery or amputation from 2007 to 2021 were identified in the Surveillance, Epidemiology and End Results (SEER) database. Demographic, socioeconomic, and oncologic variables were collected for each patient. Multivariate binary logistic regression was conducted to assess preoperative demographic and oncologic risk factors for amputation (p < 0.05).

RESULTS

A total of 6465 patients were identified in the final cohort, 586 (9.1%) of whom received amputation. After controlling for tumor size, stage, and neoadjuvant therapy administration, non-Hispanic American Indian/Alaskan Native race/ethnicity predicted the highest odds of amputation (OR: 1.78, 95% CI: 1.12-2.85, p = 0.015). Nonmetropolitan residence (OR: 1.69, 95% CI: 1.43-2.00, p < 0.001) also conferred higher risk of amputation compared with residence in a large metropolitan area. Overall, amputation was associated with a higher risk of ten-year cancer-specific mortality (p < 0.001) even when controlled by sociodemographic and clinical characteristics.

CONCLUSIONS

There are significant disparities in limb-sparing surgery and amputation rates in lower extremity sarcoma management, even when accounting for differences in baseline oncologic characteristics. Further study into socioeconomic drivers of these trends will allow the development of initiatives that improve disparities in reconstructive outcomes.

Minority pediatric burn survivors undergo more burn operations: A single center's five-year experience

Burn injuries remain a significant source of trauma in the United States and disproportionately affect racial and ethnic minorities. Although disparities are well documented in adults, less is known regarding those in pediatric populations. To address this gap in literature, we aim to better characterize burn injuries, inpatient treatments, and post-discharge outcomes in minority pediatric burn patients. We hypothesize minority patients undergo more surgery and re-admissions than non-minority patients for burn care. This is a single institution retrospective chart review of pediatric patient admissions with burn injuries from July 1st, 2016 to July 1st, 2021. Demographics, details of injury, inpatient surgical and non-surgical care, and post-discharge outcomes were collected. Patients identifying as Hispanic/Latino, Black, and Asian were coded as minority patients. Univariate analysis was utilized. A total of 332 patients with average age of 4.9 years (SD: 4.4) and average total burn surface area (TBSA) of 8.5% (SD: 10.0) were collected. Minority patients were significantly more likely to experience accidental burn injury (p < 0.01), inhalational injury (p < 0.01), surgical management (p < 0.01), and to undergo skin graft (p < 0.01) than White patients. Minority patients were significantly more likely to undergo laser treatment after discharge (p < 0.01) than White patients. Our study shows minority pediatric patients are at risk for non-intentional burn injuries that undergo surgical management such as skin grafting and longitudinal reconstructive procedures including laser therapy more often. Short-term goals should include facilitating improved physical and psychosocial outcomes in this often-underserved patient population.

Impact of race and ethnicity on presentation and outcomes of patients treated on rhabdomyosarcoma clinical trials: A report from the Children's Oncology Group

BACKGROUND

Racial and ethnic disparities have been demonstrated in pediatric and adult cancers. However, there is no consensus on whether such disparities exist in the presentation, treatment, and outcome of patients with rhabdomyosarcoma (RMS).

METHODS

Patient information from the seven most recent RMS clinical trials was obtained from the Children's Oncology Group (COG). Chi-squared analyses were used to compare patient, tumor, and treatment characteristics across racial and ethnic groups. Pairwise analyses comparing Non-Hispanic Black (NHB) versus Non-Hispanic White (NHW) racial groups and Hispanic versus NHW ethnic groups were conducted for significant characteristics. Kaplan-Meier method and Wilcoxon signed-rank tests were performed to analyze outcomes.

RESULTS

In the overall cohort (n = 2157), patients' self-identified race/ethnicity was: 0.4% American Indian/Alaska Native, 2.6% Asian, 12.6% Hispanic, 0.2% Native American/other Pacific Islander, 12.8% NHB, 61.9% NHW, and 9.6% unknown. Six characteristics differed by race/ethnicity: age, histology, IRS group, invasiveness, metastatic disease, and FOXO1 fusion partner. Five were significant in pairwise comparisons: NHB patients were more likely to present at age ≥ 10 years and with invasive tumors than NHW patients; Hispanic patients were more likely to present with alveolar histology, metastatic disease, and IRS group IV disease than NHW patients. No differences were found in event free or overall survival of the entire cohort, in risk group-based subset analyses, or among patients with high-risk characteristics significant on pairwise analysis.

CONCLUSIONS

While NHB and Hispanic patients enrolled in COG trials presented with higher risk features than NHW patients, there were no outcome differences by racial or ethnic group.

Is the Number of National Database Research Studies in Musculoskeletal Sarcoma Increasing, and Are These Studies Reliable?

BACKGROUND

Large national databases have become a common source of information on patterns of cancer care in the United States, particularly for low-incidence diseases such as sarcoma. Although aggregating information from many hospitals can achieve statistical power, this may come at a cost when complex variables must be abstracted from the medical record. There is a current lack of understanding of the frequency of use of the Surveillance, Epidemiology, and End Results (SEER) database and the National Cancer Database (NCDB) over the last two decades in musculoskeletal sarcoma research and whether their use tends to produce papers with conflicting findings.

QUESTIONS/PURPOSES

(1) Is the number of published studies using the SEER and NCDB databases in musculoskeletal sarcoma research increasing over time? (2) What are the author, journal, and content characteristics of these studies? (3) Do studies using the SEER and the NCDB databases for similar diagnoses and study questions report concordant or discordant key findings? (4) Are the administrative data reported by our institution to the SEER and the NCDB databases concordant with the data in our longitudinally maintained, physician-run orthopaedic oncology dataset?

METHODS

To answer our first three questions, PubMed was searched from 2001 through 2020 for all studies using the SEER or the NCDB databases to evaluate sarcoma. Studies were excluded from the review if they did not use these databases or studied anatomic locations other than the extremities, nonretroperitoneal pelvis, trunk, chest wall, or spine. To answer our first question, the number of SEER and NCDB studies were counted by year. The publication rate over the 20-year span was assessed with simple linear regression modeling. The difference in the mean number of studies between 5-year intervals (2001-2005, 2006-2010, 2011-2015, 2016-2020) was also assessed with Student t-tests. To answer our second question, we recorded and summarized descriptive data regarding author, journal, and content for these studies. To answer our third question, we grouped all studies by diagnosis, and then identified studies that shared the same diagnosis and a similar major study question with at least one other study. We then categorized study questions (and their associated studies) as having concordant findings, discordant findings, or mixed findings. Proportions of studies with concordant, discordant, or mixed findings were compared. To answer our fourth question, a coding audit was performed assessing the concordance of nationally reported administrative data from our institution with data from our longitudinally maintained, physician-run orthopaedic oncology dataset in a series of patients during the past 3 years. Our orthopaedic oncology dataset is maintained on a weekly basis by the senior author who manually records data directly from the medical record and sarcoma tumor board consensus notes; this dataset served as the gold standard for data comparison. We compared date of birth, surgery date, margin status, tumor size, clinical stage, and adjuvant treatment.

RESULTS

The number of musculoskeletal sarcoma studies using the SEER and the NCDB databases has steadily increased over time in a linear regression model (β = 2.51; p < 0.001). The mean number of studies per year more than tripled during 2016-2020 compared with 2011-2015 (39 versus 13 studies; mean difference 26 ± 11; p = 0.03). Of the 299 studies in total, 56% (168 of 299) have been published since 2018. Nineteen institutions published more than five studies, and the most studies from one institution was 13. Orthopaedic surgeons authored 35% (104 of 299) of studies, and medical oncology journals published 44% (130 of 299). Of the 94 studies (31% of total [94 of 299]) that shared a major study question with at least one other study, 35% (33 of 94) reported discordant key findings, 29% (27 of 94) reported mixed key findings, and 44% (41 of 94) reported concordant key findings. Both concordant and discordant groups included papers on prognostic factors, demographic factors, and treatment strategies. When we compared nationally reported administrative data from our institution with our orthopaedic oncology dataset, we found clinically important discrepancies in adjuvant treatment (19% [15 of 77]), tumor size (21% [16 of 77]), surgery date (23% [18 of 77]), surgical margins (38% [29 of 77]), and clinical stage (77% [59 of 77]).

CONCLUSION

Appropriate use of databases in musculoskeletal cancer research is essential to promote clear interpretation of findings, as almost two-thirds of studies we evaluated that asked similar study questions produced discordant or mixed key findings. Readers should be mindful of the differences in what each database seeks to convey because asking the same questions of different databases may result in different answers depending on what information each database captures. Likewise, differences in how studies determine which patients to include or exclude, how they handle missing data, and what they choose to emphasize may result in different messages getting drawn from large-database studies. Still, given the rarity and heterogeneity of sarcomas, these databases remain particularly useful in musculoskeletal cancer research for nationwide incidence estimations, risk factor/prognostic factor assessment, patient demographic and hospital-level variable assessment, patterns of care over time, and hypothesis generation for future prospective studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Survival disadvantage of male children with retinoblastoma in the United States: Surveillance Epidemiology and End Results (2000-2017) Evidence

BACKGROUND

Retinoblastoma is a rare malignancy involving the retina, although, more common among children, with genetic inheritance explaining the incidence as well as acquired forms. The incidence varies among race and sex as well as mortality and survival. The current study aimed to assess retinoblastoma cumulative incidence (CMI), mortality, and survival by sex.

METHODS

A retrospective cohort design was used to assess the CMI, mortality, and survival in this pediatric malignancy based on the Surveillance Epidemiology and End Results (SEER) data 2000-2017. The binomial regression model was used to examine sex differentials in mortality, as well as other study variables, while Cox proportional hazard model was used for the survival variability by sex.

RESULTS

The CMI during this period was higher among males relative to females (males n = 249, 56.7%; females n = 190, 43.3%, χ²  = 2.90, df = 1, p = 0.089). There were sex differences in mortality, with excess mortality observed among males compared to females, risk ratio = 3.40, 95% CI [1.0-15.72]. The survival differences by sex indicated decreased survival among males relative to females, hazard ratio (HR) = 3.39, 95% CI [1.0-15.72]. After controlling for the potential confoundings, namely tumor grade, urbanity, and median income the survival disadvantage of males persisted. Compared to females', males were more than three times as likely to die, adjusted HR = 3.42, 99% CI [0.37-31.60].

CONCLUSION

In a representative sample of pediatric retinoblastoma, there was a sex differential in survival with excess risk of dying identified among males relative to females, which may be explained in part by male X-linkage.

The Association between Race/Ethnicity and Cancer Stage at Diagnosis of Bone Malignancies: A Retrospective Cohort Study

INTRODUCTION AND OBJECTIVE

Limited data exists analyzing disparities in diagnosis regarding primary bone neoplasms (PBN). The objective of our study was to determine if there is an association between race/ethnicity and advanced stage of diagnosis of PBN.

METHODS

This population-based retrospective cohort study included patient demographic and health information extracted from the National Cancer Institute Surveillance, Epidemiology, and End Results Program (SEER). The main exposure variable was race/ethnicity categorized as non-Hispanic white (NH-W), non-Hispanic black (NH-B), non-Hispanic Asian Pacific Islander (NH-API), and Hispanic. The main outcome variable was advanced stage at diagnosis. Age, sex, tumor grade, type of bone cancer, decade, and geographic location were co-variates. Unadjusted and adjusted logistic regression analyses were conducted calculating odds ratios (OR) and corresponding 95% confidence intervals.

RESULTS

Race/ethnicity was not statistically significantly associated with advanced-stage disease. Adjusted OR for NH-B was 0.94 (95% CI: 0.78-1.38), for NH-API 1.07 (95% CI: 0.86-1.33) and for Hispanic 1.03 (95% CI: 0.85-1.25).

CONCLUSIONS

The lack of association between race and advanced stage of disease could be due to high availability and low cost for initial management of bone malignancies though plain radiographs. Future studies may include socioeconomic status and insurance coverage as covariates in the analysis.

Socioeconomic and health care coverage disparities in children, adolescents, and young adults with sarcoma

BACKGROUND

Socioeconomic and health care coverage disparities are established as poor prognostic markers in adults with sarcoma, but few studies examine these differences among pediatric, adolescents and young adults (AYA). This study examines the association between socioeconomic status (SES), insurance status, and disease presentation among children and AYA patients with sarcoma.

METHODS

This is a retrospective cohort study of patients aged 0-25 years with bone or soft tissue sarcoma from the National Cancer Database. SES assignments were based on estimated median income and education level. Patient demographics and clinical factors were compared by SES and insurance status. Multivariate logistic regression models were fitted to determine adjusted odds ratios of SES and insurance status on metastatic disease or tumor size ≥5 cm at time of presentation.

RESULTS

In a cohort of 9112 patients, 2932 (32.1%) had low, 2084 (22.8%) middle, and 4096 (44.9%) high SES. For insurance status, 5864 (64.3%) had private, 2737 (30.0%) public, and 511 (5.6%) were uninsured. Compared to high SES, patients with low SES were more likely to have metastatic disease (OR = 1.16, P = .03) and tumors ≥5 cm (OR = 1.29, P < .01). Compared to private insurance, public and no insurance were associated with metastatic disease (OR = 1.35, P < .01 and OR = 1.32, P = .02) and increased tumors ≥5 cm (OR = 1.28, P < .01 and OR = 1.67, P < .01).

CONCLUSIONS

SES disparities exist among children and AYA patients with sarcoma. Low SES and public or no insurance are associated with advanced disease at presentation. Further studies are needed to identify interventions to improve earlier detection of sarcomas in at-risk children and young adults.

Implications of transfer status on bowel loss in children undergoing emergency surgery for malrotation

OBJECTIVE

Malrotation with midgut volvulus is a time-sensitive pediatric surgical disease that requires emergent operative exploration to avoid bowel loss; however, it also requires specialized pediatric care. The purpose of this study was to identify disparities in bowel resection in children who underwent emergency surgery for malrotation; particularly the role of transfer status.

METHODS

The Pediatric Health Information System was used to identify a multicenter cohort of patients who underwent emergency surgical intervention for malrotation. Univariate and multivariable analyses were used to determine factors associated with the primary outcome of bowel resection; secondary outcomes included surgical complications, prolonged length of stay, TPN dependence, and death.

RESULTS

Of 3373 patients with malrotation included, 44.8% were transferred in. Younger age, prematurity and other comorbidity, nonwhite race, and public insurance were associated with transfer. Transferred patients were more likely to undergo bowel resection on univariate (30.7 vs 16.4%, p < .001) and multivariable analysis (RR =1.38, p < .010). After adjusting for bowel resection, only patient factors including age and comorbidity were associated with surgical complications, TPN dependence, and death.

CONCLUSION

Patients who require hospital-to-hospital transfer for emergent surgical management of malrotation are more likely to require bowel resection which is in turn associated with greater morbidity. Further work is needed to optimize access to prompt surgical care for this condition especially given race and insurance disparities in transfer status.

LEVEL OF EVIDENCE

III, prognostic study.

The impact of racial/ethnic disparities on survival for children and young adults with chest wall sarcoma: A population-based study

BACKGROUND

To determine whether there are racial/ethnic disparities in disease presentation, treatment and survival outcomes among children and young adults with chest wall sarcomas.

METHODS

The Surveillance, Epidemiology and End Results (SEER) database was analyzed for patients 21 years old and younger with chest wall sarcoma. We performed multivariate logistic regression to investigate the association of race/ethnicity with advanced stage of disease at presentation and likelihood of undergoing surgical resection. Overall survival (OS) was evaluated using Cox regression modeling to calculate hazard ratios with 95% confidence intervals.

RESULTS

A total of 669 patients were identified: 393 non-Hispanic whites (NHW) (59%), 151 Hispanics (23%), 64 non-Hispanic blacks (NHB) (11%), and 64 other race/ethnicity (9%). The 5- and 10-year OS rates for the entire cohort were 69% and 64%, respectively. NHB had significantly worse 5-year and 10-year OS compared to NHW based on the log rank test (61% versus 70%, 52% versus 66%, respectively; p = 0.037).). Most patients (80%) underwent surgical resection. However, NHB were less likely than NHW to undergo surgical resection by multivariate analysis (OR 0.43, 95% CI 0.22-0.82).

CONCLUSIONS

NHB children and young adults with chest wall sarcoma have decreased overall survival. In addition, NHB are less likely to undergo surgical resection which may contribute to survival disparities. It is paramount that health care providers work to close the treatment gap between racial/ethnic groups to improve survival in children and young adults with chest wall sarcoma.

LEVEL OF EVIDENCE

Level III Treatment Study.