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Mani K, Kleinbart E, Schlumprecht A, Golding R, Akioyamen N, Song H, De La Garza Ramos R, Eleswarapu A, Yang R, Geller D, Hoang B, Fourman MS. Association of Socioeconomic Status With Worse Overall Survival in Patients With Bone and Joint Cancer. J Am Acad Orthop Surg 2024; 32:e346-e355. [PMID: 38354415 DOI: 10.5435/jaaos-d-23-00718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/25/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND The effect of socioeconomic status (SES) on the outcomes of patients with metastatic cancer to bone has not been adequately studied. We analyzed the association between the Yost Index, a composite geocoded SES score, and overall survival among patients who underwent nonprimary surgical resection for bone metastases. METHODS This population-based study used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010 to 2018). We categorized bone and joint sites using International Classification of Disease-O-3 recodes. The Yost Index was geocoded using a factor analysis and categorized into quintiles using census tract-level American Community Service 5-year estimates and seven measures: median household income, median house value, median rent, percent below 150% of the poverty line, education index, percent working class, and percent unemployed. Multivariate Cox regression models were used to calculate adjusted hazard ratios of overall survival and 95% confidence intervals. RESULTS A total of 138,158 patients were included. Patients with the lowest SES had 34% higher risk of mortality compared with those with the highest SES (adjusted hazard ratio of 1.34, 95% confidence interval: 1.32 to 1.37, P < 0.001). Among patients who underwent nonprimary surgery of the distant bone tumor (n = 11,984), the age-adjusted mortality rate was 31.3% higher in the lowest SES patients compared with the highest SES patients (9.9 versus 6.8 per 100,000, P < 0.001). Patients in the lowest SES group showed more racial heterogeneity (63.0% White, 33.5% Black, 3.1% AAPI) compared with the highest SES group (83.9% White, 4.0% Black, 11.8% AAPI, P < 0.001). Higher SES patients are more likely to be married (77.5% versus 59.0%, P < 0.0001) and to live in metropolitan areas (99.6% versus 73.6%, P < 0.0001) compared with lower SES patients. DISCUSSION Our results may have implications for developing interventions to improve access and quality of care for patients from lower SES backgrounds, ultimately reducing disparities in orthopaedic surgery.
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Affiliation(s)
- Kyle Mani
- From the Albert Einstein College of Medicine (Mani, Kleinbart, Golding, and Song), the Department of Neurological Surgery, Montefiore Einstein (Schlumprecht, and De La Garza Ramos), and the Department of Orthopaedic Surgery, Montefiore Einstein, Bronx, NY (Akioyamen, Eleswarapu, Yang, Geller, Hoang, and Fourman)
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Dunlop HM, Atchison TJ, Zeh R, Konieczkowski DJ, Kim A, Grignol VP, Contreras CM, Obeng-Gyasi S, Pawlik TM, Pollock RE, Beane JD. Preoperative radiation therapy increases adherence in patients with high-risk extremity soft tissue sarcoma. Surgery 2024; 175:756-764. [PMID: 37996341 DOI: 10.1016/j.surg.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/26/2023] [Accepted: 10/24/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Surgery and radiation therapy remain the standard of care for patients with high-grade extremity soft tissue sarcoma that are >5 cm. Radiation therapy is time and labor-intensive for patients, and social determinants of health may affect adherence. The aim of this study was to define demographic, clinical, and treatment factors associated with the completion of radiation therapy and determine if preoperative radiation therapy improved adherence compared to postoperative radiation therapy. METHODS The cohort included patients in the National Cancer Database with high-grade extremity soft tissue sarcoma >5 cm without nodal or distant metastases who received limb-sparing surgery and radiation therapy with microscopically negative R0 margins. Multivariable logistic regression analyses identified factors associated with radiation therapy sequencing and adherence (defined as completion of 50 Gy preoperative radiation therapy or at least 60 Gy postoperative radiation therapy). A multivariable Cox Proportional Hazards model assessed overall survival. RESULTS Among 2,145 patients, 47.1% received preoperative radiation therapy (n = 1,010), and 52.9% (n = 1135) received postoperative radiation therapy. A greater proportion of patients treated with preoperative (77.2%) versus postoperative radiation therapy (64.9%, P < .0001) received the recommended dose. More patients with private insurance (49.8% vs 35.3% Medicaid vs 44.9% Medicare, P = .011) and patients treated at an academic medical center (52.6% vs 47.4%, P < .001) received preoperative radiation therapy. Patients who received preoperative radiation therapy had lower odds of receiving insufficient doses of radiation therapy (odds ratio 0.34 [95% CI 0.27-0.47]). Neither radiation therapy adherence nor sequencing were independent predictors of overall survival. CONCLUSIONS Patients who received preoperative radiation therapy were more likely to complete therapy and receive an optimal dose than patients treated with postoperative radiation therapy. Preoperative radiation therapy improves adherence and should be widely considered in patients with high-grade extremity soft tissue sarcoma, particularly in patients at risk for not completing therapy.
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Affiliation(s)
| | - T J Atchison
- The Ohio State University College of Medicine, Columbus, OH
| | - Ryan Zeh
- The University of Pittsburgh, Department of Surgery, Pittsburgh, PA
| | - David J Konieczkowski
- The Ohio State University Wexner Medical Center, Department of Radiation Oncology, Columbus, OH
| | - Alex Kim
- The Ohio State University Wexner Medical Center, Department of Surgical Oncology, Columbus, OH
| | - Valerie P Grignol
- The Ohio State University Wexner Medical Center, Department of Surgical Oncology, Columbus, OH
| | - Carlo M Contreras
- The Ohio State University Wexner Medical Center, Department of Surgical Oncology, Columbus, OH
| | - Samilia Obeng-Gyasi
- The Ohio State University Wexner Medical Center, Department of Surgical Oncology, Columbus, OH
| | - Timothy M Pawlik
- The Ohio State University Wexner Medical Center, Department of Surgical Oncology, Columbus, OH
| | - Raphael E Pollock
- The Ohio State University Wexner Medical Center, Department of Surgical Oncology, Columbus, OH
| | - Joal D Beane
- The Ohio State University Wexner Medical Center, Department of Surgical Oncology, Columbus, OH.
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Mentrup F, Klein A, Lindner LH, Nachbichler S, Holzapfel BM, Albertsmeier M, Knösel T, Dürr HR. Refusal of Adjuvant Therapies and Its Impact on Local Control and Survival in Patients with Bone and Soft Tissue Sarcomas of the Extremities and Trunk. Cancers (Basel) 2024; 16:239. [PMID: 38254731 PMCID: PMC10814158 DOI: 10.3390/cancers16020239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND In soft tissue or bone sarcomas, multimodal therapeutic concepts represent the standard of care. Some patients reject the therapeutic recommendations due to several reasons. The aim of this study was to assess the impact of that rejection on both prognosis and local recurrence. METHODS Between 2012 and 2019, a total of 828 sarcoma patients were surgically treated. Chemotherapy was scheduled as a neoadjuvant, and adjuvant multi-agent therapy was performed following recommendations from an interdisciplinary tumor board. Radiotherapy, if deemed appropriate, was administered either in a neoadjuvant or an adjuvant manner. The recommended type of therapy, patient compliance, and the reasons for refusal were documented. Follow-ups included local recurrences, diagnosis of metastatic disease, and patient mortality. RESULTS Radiotherapy was recommended in 407 (49%) patients. A total of 40 (10%) individuals did not receive radiation. A reduction in overall survival and local recurrence-free survival was evident in those patients who declined radiotherapy. Chemotherapy was advised for 334 (40%) patients, 250 (75%) of whom did receive all recommended cycles. A total of 25 (7%) individuals did receive a partial course while 59 (18%) did not receive any recommended chemotherapy. Overall survival and local recurrence-free survival were reduced in patients refusing chemotherapy. Overall survival was worst for the group of patients who received no chemotherapy due to medical reasons. Refusing chemotherapy for non-medical reasons was seen in 8.8% of patients, and refusal of radiotherapy for non-medical reasons was seen in 4.7% of patients. CONCLUSIONS Divergence from the advised treatment modalities significantly impacted overall survival and local recurrence-free survival across both treatment modalities. There is an imperative need for enhanced physician-patient communication. Reducing treatment times, as achieved with hypofractionated radiotherapy and with therapy in a high-volume sarcoma center, might also have a positive effect on complying with the treatment recommendations.
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Affiliation(s)
- Franziska Mentrup
- Department of Orthopaedics and Trauma Surgery, Orthopaedic Oncology, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, 81377 München, Germany; (F.M.); (A.K.); (B.M.H.)
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
| | - Alexander Klein
- Department of Orthopaedics and Trauma Surgery, Orthopaedic Oncology, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, 81377 München, Germany; (F.M.); (A.K.); (B.M.H.)
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
| | - Lars Hartwin Lindner
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
- Department of Medicine III, LMU University Hospital, LMU Munich, 81377 München, Germany
| | - Silke Nachbichler
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, 81377 München, Germany
| | - Boris Michael Holzapfel
- Department of Orthopaedics and Trauma Surgery, Orthopaedic Oncology, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, 81377 München, Germany; (F.M.); (A.K.); (B.M.H.)
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
| | - Markus Albertsmeier
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, 81377 München, Germany
| | - Thomas Knösel
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
- Institute of Pathology, LMU Munich, 81377 München, Germany
| | - Hans Roland Dürr
- Department of Orthopaedics and Trauma Surgery, Orthopaedic Oncology, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, 81377 München, Germany; (F.M.); (A.K.); (B.M.H.)
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
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Tortorello GN, Sharon CE, Ma KL, Perry N, Shabason JE, Maki RG, Miura JT, Karakousis GC. Neoadjuvant chemotherapy in patients undergoing neoadjuvant radiation for trunk and extremity soft tissue sarcoma. J Surg Oncol 2023; 128:628-634. [PMID: 37148468 DOI: 10.1002/jso.27307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/03/2023] [Accepted: 04/24/2023] [Indexed: 05/08/2023]
Abstract
INTRODUCTION Many patients with high-risk soft tissue sarcoma (STS) develop distant metastases. Meta-analyses suggest that chemotherapy confers a small survival benefit, though few studies focus on neoadjuvant chemotherapy (NCT). There has been more frequent use of neoadjuvant radiation therapy (NRT) in STS, but the utility of NCT for these patients remains unclear. METHODS Patients with stage II-III trunk/extremity STS who underwent NRT and resection were identified using the National Cancer Database (2006-2019). Predictors of NCT were analyzed using logistic regression. Change in rate of NCT use over time was assessed using log-linear regression modeling. Survival was examined using Kaplan-Meier (KM) and Cox proportional hazard modeling. RESULTS Of 5740 patients, 25% underwent NCT. The overall median age was 62, 55% of patients were male, and 67% had stage III disease. The most common histological subtypes were fibrosarcoma/myxofibrosarcoma (39%) and liposarcoma (16%). Use of NCT decreased by 4.0% per year throughout the study period (p < 0.01). Predictors of NCT included younger age (median 54, IQR 42-64 vs. median 65, IQR 53-75, p < 0.01), treatment at an academic center (odds ratio [OR] 1.5, p < 0.01), and stage III disease (OR 2.2, p < 0.01). Histologic predictors of NCT included synovial sarcoma (52%) and angiosarcoma (45%). With a median follow-up time of 77 months, NCT was associated with improved 5-year survival compared to NRT alone on KM analysis (70% vs. 63%, p < 0.01). This difference persisted on multivariate analysis (hazard ratio 0.86, p = 0.027) and after propensity matching (70% vs. 65%, p = 0.0064). CONCLUSION Despite risk of distant failure in high-risk STS, use of NCT has decreased over time in patients receiving NRT. In this retrospective analysis, NCT was associated with a modestly improved overall survival.
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Affiliation(s)
- Gabriella N Tortorello
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cimarron E Sharon
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin L Ma
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nikhita Perry
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacob E Shabason
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert G Maki
- Department of Medicine, Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John T Miura
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Giorgos C Karakousis
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Valle LF, Bernthal N, Eilber FC, Shabason JE, Bedi M, Kalbasi A. Evaluating Thresholds to Adopt Hypofractionated Preoperative Radiotherapy as Standard of Care in Sarcoma. Sarcoma 2021; 2021:3735874. [PMID: 34720663 PMCID: PMC8556117 DOI: 10.1155/2021/3735874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/14/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Data supporting hypofractionated preoperative radiation therapy (RT) for patients with extremity and trunk soft tissue sarcoma (STS) are currently limited to phase II single-institution studies. We sought to understand the type and thresholds of clinical evidence required for experts to adopt hypofractionated RT as a standard-of-care option for patients with STS. METHODS An electronic survey was distributed to multidisciplinary sarcoma experts. The survey queried whether data from a theoretical, multi-institutional, phase II study of 5-fraction preoperative RT could change practice. Using endpoints from RTOG 0630 as a reference, the survey also queried thresholds for acceptable local control, wound complication, and late toxicity for the study protocol to be accepted as a standard-of-care option. Responses were logged from 8/27/2020 to 9/8/2020 and summarized graphically. RESULTS The survey response rate was 55.3% (47/85). Local control is the most important clinical outcome for sarcoma specialists when evaluating whether an RT regimen should be considered standard of care. 17% (8/47) of providers require randomized phase III evidence to consider hypofractionated preoperative RT as a standard-of-care option, whereas 10.6% (5/47) of providers already view this as a standard-of-care option. Of providers willing to change practice based on phase II data, most (78%, 29/37) would accept local control rates equivalent to or less than those in RTOG 0630, as long as the rate was higher than 85%. However, 51.3% (19/37) would require wound complication rates superior to those reported in RTOG 0630, and 46% (17/37) of respondents would accept late toxicity rates inferior to RTOG 0630. CONCLUSION Consensus building is needed among clinicians regarding the type and threshold of evidence needed to evaluate hypofractionated RT as a standard-of-care option. A collaborative consortium-based approach may be the most pragmatic means for developing consensus protocols and pooling data to gradually introduce hypofractionated preoperative RT into routine practice.
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Affiliation(s)
- Luca F. Valle
- Department of Radiation Oncology, Jonsson Comprehensive Cancer Center and David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Nicholas Bernthal
- Department of Orthopedic Surgery, Jonsson Comprehensive Cancer Center and David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Fritz C. Eilber
- Departments of Surgery, Jonsson Comprehensive Cancer Center and David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Jacob E. Shabason
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anusha Kalbasi
- Department of Radiation Oncology, Jonsson Comprehensive Cancer Center and David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
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