Social Determinants of Health Impact on Survival of Patients With Malignant Pleural Mesothelioma

Our plain-English summary of Social Determinants of Health Impact on Survival of Patients With Malignant Pleural Mesothelioma, by A. Alnajar, S.A. Kareff, S.S. Razi, et al (Annals of Thoracic Surgery Short Reports, 2023).

The study

• Authors: A. Alnajar, S.A. Kareff, S.S. Razi, J.S. Rao, D.M. Nguyen, N. Villamizar, E. Rodriguez
• Journal: Annals of Thoracic Surgery Short Reports
• Published: 2023;1(4):548-552
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Patients with malignant pleural mesothelioma (MPM) have a high mortality risk, even after optimal management and accounting for differences in comorbidities. We aimed to assess the overall survival of patients with operable MPM based on social determinants of health (SDH). We hypothesized that an SDH score can predict patients with poorer overall survival despite optimal management.

Methods: This study used a retrospective analysis of the National Cancer Database from 2004 to 2017. Adult patients with clinical stage I-IIIA MPM were included. Based on patients' personal and geographic characteristics, we constructed an SDH score index that identifies patients of socioeconomic disadvantage by the following variables: income, education, geography, and hospital types within 250 miles. We performed a survival analysis using the Kaplan-Meier method as well as univariable and multivariable Cox regression models.

Results: Higher composite SDH scores demonstrated worse outcomes. Overall increased disadvantage increased the risk of mortality by 21% (hazard ratio [HR], 1.21; CI, 1.12-1.30), with a higher increase of 57% for score ≥2 (HR,1.57; CI, 1.36-1.81). After accounting for age, stage, comorbidities, multimodal therapy, and hospital volume and type, the SDH score index remained statistically significant, with a 29% increased risk of mortality for score ≥2 compared with ≤1 (HR, 1.29; CI, 1.10-1.50). Curative surgery with chemotherapy reduced mortality risk by 29% (HR, 0.71; CI, 0.62-0.81) after adjustment for patients' SDH scores and other relevant factors.

Conclusions: Various SDH factors affect survival outcomes independently of treatment modality and patient characteristics. This SDH composite score could help identify patients with socioeconomic disadvantages at risk for suboptimal survival outcomes.

© 2023 The Authors.

In plain English

This retrospective study used the US National Cancer Database to test whether social and economic disadvantage was linked to survival in 1355 adults with operable (clinical stage I-IIIA) malignant pleural mesothelioma diagnosed from 2004 to 2017. It did not examine asbestos exposure. The authors built a score that gave 1 point each for low income, low education, distance from metropolitan areas and the types of hospital within 250 miles. For the whole group, estimated survival was 74% (72%-77%) at 1 year and 19% (17%-21%) at 5 years. In unadjusted analysis, each one-point rise in the score was linked to a higher risk of death (hazard ratio 1.21, CI 1.12-1.30). Patients scoring 2 or more had a hazard ratio of 1.57 (CI 1.36-1.81) compared with those scoring 0-1. After adjusting for factors including age, stage, other illnesses, treatment and hospital type and volume, that hazard ratio was 1.29 (CI 1.10-1.50). Surgery with chemotherapy was linked to a lower risk of death. The authors concluded that social determinants of health affected survival independently of treatment. They noted that their score had not been externally validated.

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), with Kaplan-Meier survival analysis and univariable and multivariable Cox regression
• Who was studied: 1355 adult patients (age limits 18 to 75) with clinical stage I-IIIA malignant pleural mesothelioma of epithelioid or biphasic type, recorded in the US National Cancer Database from 2004 through 2017. Of these, 768 received surgery as part of multimodality therapy and 587 received chemotherapy without surgery.
• Exposure: Not an asbestos exposure study. The exposure was a composite social determinants of health score, with 1 point per risk factor: income, education, distance from metropolitan areas, and hospital types within a 250-mile radius. Patients were grouped as low (0-1) or high (2-4).
• Main results:
  • For the entire cohort, estimated survival was 74% (72%-77%) at 1 year and 19% (17%-21%) at 5 years. Median survival was 1.79 years (22 months). There were 1137 deaths at last follow-up.
  • Unadjusted analysis: each increase in the score was associated with higher mortality (HR 1.21, CI 1.12-1.30). Patients with a score of 2 or more had an HR of 1.57 (CI 1.36-1.81) compared with the low-score group.
  • Adjusted analysis: a score of 2 or more remained associated with higher mortality compared with a score of 1 or less (HR 1.29, CI 1.10-1.50), after accounting for age, stage, comorbidities, multimodal therapy, and hospital volume and type.
  • Survival was longer at all time points for patients scoring 1 or less than for those scoring 2 or more. The largest absolute difference, 17%, was in 1-year survival.
  • Individual score factors associated with mortality: poor income (HR 1.13 [1.01-1.27]), no community hospital within 250 miles (HR 1.34 [1.18-1.52]), and distance from metropolitan areas (HR 1.42 [1.06-1.91]).
  • In the adjusted analysis, increasing age, male sex (HR 1.50, 95% CI 1.30-1.73) and Black race (HR 1.39, 95% CI 1.02-1.90) were associated with higher mortality. Epithelioid histology, compared with biphasic, was associated with lower mortality (HR 0.64, 95% CI 0.56-0.75).
  • Chemotherapy plus surgical treatment was associated with lower mortality. In the adjusted table the HR was 0.72 (95% CI 0.63-0.82); the article's abstract gives HR 0.71 (CI 0.62-0.81).
  • Patients who had surgery were less often in the high-score group: 101 of 768 (13%), compared with 179 of 587 (30%) of chemotherapy-only patients.
• The authors' conclusion: The authors concluded that surgical treatment reduces mortality in operable malignant pleural mesothelioma, but that nonclinical, nonbiologic social determinants of health also independently affect survival. They suggested this exploratory score could help identify disadvantaged patients at risk of worse survival.
• Limitations the authors state:
  • The score lacked external validation. Patients not treated at centers covered by the National Cancer Database may have been excluded, because of changes in accreditation status or social disadvantage limiting referral.
  • The National Cancer Database does not track patients across multiple centers, so patients may have been diagnosed or given systemic therapy at one center and had surgery at another.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Overall Survival, Hazard Ratio, Multimodal Therapy, Chemotherapy.

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