Differentiating the General Vestibular Schwannoma Patient Population, Tertiary Referral Center Cohorts, and the Acoustic Neuroma Association Survey Respondents: A Response to the Benefits and Drawbacks of Survey-Based Studies

Socioeconomic determinants impact quality of life at vestibular schwannoma diagnosis

BACKGROUND

Socioeconomic variables including race, education, and income have been shown to affect vestibular schwannoma incidence, treatment, and outcomes. We sought to determine the impact of socioeconomic factors on quality of life at the time of vestibular schwannoma diagnosis.

METHODS

Retrospective cohort study conducted at a tertiary academic center. All patients evaluated for vestibular schwannoma from March 1, 2010 to December 31, 2021 who completed at least one Penn Acoustic Neuroma Quality of Life (PANQOL) questionnaire at presentation or prior to any intervention were included. PANQOL scores were compared across income quintiles, racial groups, and health insurance categories.

RESULTS

Two-hundred and ninety-six patients who had non-missing information on variables of interest were included. Compared to White/Caucasian patients (84.5 %), Black/African American patients (4.7 %) had significantly lower PANQOL total scores (b = -12.8[-21.7, -4.0], p = 0.005). Compared to patients with Commercial insurance (53 %), patients who were Uninsured/ Self-pay (1.7 %) had significantly lower PANQOL total scores (b = -16.7[-31.4, -1.9], p = 0.027). Patients in higher income quintiles had significantly higher PANQOL total scores (b = 11.7[3.9, 19.5], p = 0.004 comparing highest income quintile to lowest). After controlling for potential confounders, income quintile (b = 9.6[1.3, 17.9], p = 0.023 comparing highest quintile to lowest) and insurance (b = -17.0[-31.9, -21], p = 0.025 comparing Uninsured/Self-pay to Commercial insurance) remained predictors of total PANQOL score.

CONCLUSIONS

Socioeconomic factors including race, health insurance, and income appear to contribute to quality of life at the time of vestibular schwannoma diagnosis. These variables are interrelated and the effects of race may be mediated in part by differences in income and health insurance coverage.

Hearing Preservation in Observed Sporadic Vestibular Schwannoma: A Systematic Review

OBJECTIVE

To characterize the natural history of hearing loss for patients presenting with serviceable hearing (SH) who undergo a wait-and-scan approach for sporadic vestibular schwannoma (VS) using aggregate time-to-event survival analysis.

STUDY DESIGN

Systematic review.

SETTING

Published international English literature, January 1, 2000 to May 31, 2020.

PATIENTS

Patients with sporadic VS entering a wait-and-scan approach with SH at diagnosis.

INTERVENTIONS

Observation with serial MRI and audiometry.

RESULTS

In total, 3,652 patients from 26 studies were included for analysis. Mean age at diagnosis was 58.8 years (SD, 4.1). Mean follow-up was 49.2 months (SD, 26.5). In total, 755 patients (21%) failed conservative treatment and underwent radiosurgery or microsurgery at the time of last follow-up. The average loss to follow-up was 6.9% (SD, 11.1). A total of 1,674 patients had SH at the time of diagnosis. Survival rates for maintaining SH were 96% at 1 year, 77% at 3 years, 62% at 5 years, and 42% at 10 years following diagnosis.

CONCLUSION

In this systematic review, aggregate data from 3,652 patients across 26 studies show consistent patterns in progression of hearing loss during observation for patients with sporadic VS as a function of time. As an easy-toremember conservative benchmark for those presenting with SH at diagnosis: approximately 75% retain SH at 3 years, 60% at 5 years, and 40% at 10 years.

Hearing Status and Aural Rehabilitative Profile of 878 Patients With Sporadic Vestibular Schwannoma

OBJECTIVES/HYPOTHESIS

To examine the hearing status and aural rehabilitative profile in a national cohort of patients with sporadic vestibular schwannoma (VS).

STUDY DESIGN

Cross-sectional survey METHODS: A cross-sectional survey of Acoustic Neuroma Association members diagnosed with sporadic VS was performed from February 2017 through January 2019. Self-reported results were used to determine the aural rehabilitative profile of respondents.

RESULTS

Among survey respondents, 62.2% (546/878) were not using any hearing-assistive device at time of survey. For the 37.8% (332/878) that were utilizing hearing-assistive devices, 32.8% (109/332) reported using a behind-the-ear hearing aid, 23.8% (79/332) used a contralateral routing of signal (CROS) hearing aid, and 21.7% (72/332) used a bone conduction device. Notably, 41.9% (278/663) of patients who previously underwent tumor treatment reported utilizing a hearing rehabilitation device at some point during VS management compared to 27.0% (58/215) of those undergoing observation with serial imaging (P < .001). Of 275 patients with functional hearing in the ipsilateral ear, 26.5% (73/275) reported having used at least one type of hearing device; 24.0% (66/275) reported use of a conventional hearing aid, 0.7% (2/275) a CROS aid, and 0.4% (1/275) a bone conduction device. Among respondents reporting ipsilateral nonfunctional hearing, 44.9% (258/575) reported having used at least one type of hearing device; 13.0% (75/575) a CROS aid, and 12.3% (71/575) a bone conduction device.

CONCLUSIONS

Even among a cohort with presumably elevated literacy surrounding hearing rehabilitation options, few patients with a history of unilateral vestibular schwannoma ultimately use hearing assistive devices long-term, suggesting that most patients sufficiently adjust to unilateral hearing loss or are unsatisfied with the benefits achieved with current device options.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1378-1381, 2021.

Regional variation in vestibular schwannoma management and patient support group participation across the United States

PURPOSE

The Acoustic Neuroma Association (ANA) represents the largest existing patient support organization for those diagnosed with vestibular schwannoma (VS) in the United States. Yet, the degree to which the ANA is actually utilized across the country is unknown. Moreover, evidence suggests that there may exist significant regional variation in management practices of VS across the United States.

MATERIALS AND METHODS

Patient participation in the ANA by state and geographical region, as well as their management approach, was reviewed through a cross-sectional survey performed from February 2017 through January 2019, patients diagnosed with sporadic VS.

RESULTS

Among 878 patients studied, the District of Columbia had the largest proportion of ANA patients relative to state population (0.85 per 100,000 persons), followed by New Hampshire (0.74), Maine (0.60), and New Jersey (0.42). Comparatively, Mississippi (0.03), Hawaii (0.07), and Rhode Island (0.09) harbored significantly lower participation rates (p = 0.001). Significant treatment variations were observed across the United States: in Maine, Iowa, Missouri, Kansas, and New Hampshire, an average of 73% (range, 70-75) of patients underwent microsurgery, whereas only 24% (range, 0-35) of patients in Colorado, New York, Massachusetts, Connecticut, and West Virginia underwent microsurgery (p < 0.001). After controlling for patient age and tumor size, patients were significantly more likely to undergo a retrosigmoid approach than the translabyrinthine approach for medium- to large-sized tumors in the Northeast (OR = 4.18; p = 0.001) and Western United States (OR = 2.94; p = 0.009).

CONCLUSIONS

Large regional variation exists surrounding patient participation in the ANA as well as management practices across the United States.

Quantifying Tertiary Referral Center Bias in Vestibular Schwannoma Research

OBJECTIVE

The majority of research influencing our understanding of vestibular schwannoma (VS) comes from large tertiary referral centers, and as a consequence, is inherently prone to referral bias. The objective of the current study was to characterize tertiary referral center bias in VS research.

STUDY DESIGN

Single-institution retrospective clinical, audiometric, and radiologic review.

SETTING

One tertiary referral center.

PATIENTS

One hundred twenty-three patients with sporadic VS treated at our institution, consisting of a local cohort of all 41 VS patients residing in the same US county as our medical center and a referral cohort of 82 patients from outside counties matched 2:1 based on age, sex, and year of diagnosis.

INTERVENTION

Surgical resection, stereotactic radiosurgery (SRS), observation.

MAIN OUTCOME MEASURES

Clinical manifestations, audiometric and radiologic findings, elected treatment modality.

RESULTS

Local patients had significantly longer follow-up after initial presentation compared to referral patients (median 4.0 vs 2.2 yr; p = 0.007). Referral patients were significantly less likely to have an incidental VS diagnosis (1% vs. 29%; p < 0.001) and presented with worse symptomatology such as hearing loss (80% vs. 54%; p = 0.002), dizziness (72% vs. 44%; p = 0.002), headache (29% vs. 15%; p = 0.075), and other cranial nerve dysfunction (11% vs. 0%; p = 0.029). Audiometrically, referral patients had significantly poorer word recognition scores at presentation (median 70% vs. 90%; p = 0.043). Local patients were more likely to have tumors confined to the IAC compared with referral patients, and had significantly smaller tumors when restricted to this region (median 4.0 vs 6.5 mm; p = 0.005). Referral patients were significantly more likely to undergo definitive management with either radiosurgery or microsurgery following primary evaluation compared to local patients (48% vs. 24%; p = 0.013).

CONCLUSION

These data suggest that the majority of existing literature surrounding VS likely suffers from referral bias, whereby disease characteristics and management decisions are distinct from that of the general VS patient population.