Racial Disparities in Treatment Patterns and Survival Among Surgically Treated Malignant Pleural Mesothelioma Patients

Our plain-English summary of Racial Disparities in Treatment Patterns and Survival Among Surgically Treated Malignant Pleural Mesothelioma Patients, by N. Alpert, M. van Gerwen, M. Steinberg, et al (Journal of Immigrant and Minority Health, 2020).

The study

• Authors: N. Alpert, M. van Gerwen, M. Steinberg, N. Ohri, R. Flores, E. Taioli
• Journal: Journal of Immigrant and Minority Health
• Published: 2020;22(6):1163-1171
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Surgery may improve survival in malignant pleural mesothelioma (MPM) patients. We examined treatment and survival in black and white surgical MPM patients using the National Cancer Database (NCDB). Among patients with pleurectomy/decortication (PD) or extrapleural pneumonectomy (EPP), multivariable logistic regressions were used to evaluate racial differences in surgical extent, additional treatment, and 30-/90-day mortality. Multivariable and propensity matched models were used to assess differences in survival. We identified 2550 patients; 2462 white (96.5%), 88 black (3.5%). Black patients were significantly less likely to receive EPP (ORadj 0.36, 95% CI 0.17-0.78) and trended towards worse 30-/90-day mortality (ORadj 1.54, 95% CI 0.59-4.03; ORadj 1.59, 95% CI 0.80-3.17, respectively). There was no difference in survival (HRadj 0.94, 95% CI 0.71-1.25). Surgery conferred a survival benefit (HRadj 0.77, 95% CI 0.73-0.82), but it varied by race (HRadj[white] 0.76, 95% CI 0.72-0.81; HRadj[black] 0.93, 95% CI 0.67-1.29). With the limitation of a small proportion of surgically resected black MPM patients in this population-based analysis, black patients were noted to undergo less extensive surgery. Although there was an overall survival benefit noted with surgery, this was not consistent across races, despite trends towards worse short-term mortality in black patients.

In plain English

This study used the US National Cancer Database to compare treatment and survival between black and white patients with malignant pleural mesothelioma who had surgery and were diagnosed between 2004 and 2013. Of 2550 surgical patients, 2462 were white and 88 were black. The study did not measure asbestos exposure. After adjusting for other factors, black patients were less likely than white patients to have the more extensive operation, extrapleural pneumonectomy, rather than pleurectomy/decortication (odds ratio 0.36, 95% CI 0.17–0.78). The differences between black and white patients were not statistically significant for receiving additional chemotherapy or radiotherapy, for death within 30 or 90 days of surgery, and for overall survival (hazard ratio 0.94, 95% CI 0.71–1.25). Black patients trended towards higher short-term mortality. In a further analysis of a larger group that also included patients without surgery, surgery was linked to a statistically significant survival benefit for white patients but not for black patients. The authors concluded that black patients had less extensive surgery but survival that was not significantly different. They noted that the small number of black patients may limit the conclusions.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of a national cancer registry database (National Cancer Database), using multivariable logistic and Cox regression and a 2:1 propensity-matched comparison
• Who was studied: Of 23,414 mesothelioma patients in the US National Cancer Database diagnosed 2004–2013, 2550 black and white patients with malignant pleural mesothelioma who had surgery and met selection criteria: 2462 white (96.5%) and 88 black (3.5%)
• Exposure: The main factor studied was race (black vs white). Outcomes were type of surgery (pleurectomy/decortication vs extrapleural pneumonectomy), receipt of additional chemotherapy or radiotherapy, 30- and 90-day mortality after surgery, and overall survival. Asbestos exposure was not measured.
• Main results:
  • After adjustment, black patients were significantly less likely than white patients to receive extrapleural pneumonectomy rather than pleurectomy/decortication (ORadj 0.36, 95% CI 0.17–0.78).
  • There was no statistically significant difference between black and white patients in receipt of additional treatment (ORadj 0.79, 95% CI 0.47–1.34).
  • There was no statistically significant difference in 30-day mortality (ORadj 1.54, 95% CI 0.59–4.03) or 90-day mortality (ORadj 1.59, 95% CI 0.80–3.17) for black compared with white patients.
  • There was no statistically significant difference in overall survival for black vs white patients (HRadj 0.94, 95% CI 0.71–1.25). Overall survival at 2 years was 31.2% (white) and 33.6% (black); at 5 years it was 10.6% (white) and 16.7% (black).
  • In the propensity-matched cohort (68 black and 136 white patients), there was no statistically significant difference in overall survival (HR 0.99, 95% CI 0.71–1.38), 30-day mortality (OR 1.62, 95% CI 0.51–5.19) or 90-day mortality (OR 2.00, 95% CI 0.89–4.51). Black patients continued to trend towards higher short-term mortality.
  • In a post-hoc analysis of a larger cohort that included patients without surgery, surgery conferred a statistically significant survival benefit for white patients (HRadj 0.76, 95% CI 0.72–0.81) but not for black patients (HRadj 0.93, 95% CI 0.67–1.29).
  • In the post-hoc analysis, the survival benefit of chemotherapy was similar by race. The benefit of radiotherapy appeared greater for black patients (HRadj 0.51, 95% CI 0.26–1.00) than for white patients (HRadj 0.84, 95% CI 0.75–0.94).
• The authors' conclusion: The authors concluded that black patients underwent less extensive surgery, but their survival was not significantly different from that of white patients. They also concluded that the overall survival benefit seen with surgery was not consistent across races, with trends towards worse short-term mortality in black patients.
• Limitations the authors state:
  • The number of black patients with surgically treated malignant pleural mesothelioma was small, which may limit the conclusions.
  • The NCDB is not designed as a nationally representative population-based sample, though the authors state it is most likely representative at a regional level.
  • The authors could not examine additional treatments in detail, such as whether treatment was given before surgery (neo-adjuvant) or the dose and type of radiotherapy.
  • The database lacked patient-level socio-economic status, specific comorbidities, type of chemotherapy and other factors, and had incomplete detailed histology.
  • Only the first course of treatment is recorded, so treatments added after disease progression were not captured.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Pleurectomy/Decortication (P/D), Extrapleural Pneumonectomy (EPP), Overall Survival.

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