Socio-economic patterning in early mortality of patients aged 0-49 years diagnosed with primary bone cancer in Great Britain, 1985-2008

The Impact of Social Determinants of Health on the Prognosis of Primary Bone Tumors: A Systematic Review

BACKGROUND

Although the prevalence of primary bone tumors (PBTs) was reported to be relatively low, they represent a difficult category of tumors for appropriate prediction, prevention, diagnosis, and treatment. Among different factors contributing to the prognosis and treatment outcomes of patients with these tumors, it is assumed that social determinants of health (SDOH) have not been well investigated nor applied in the process of decision making for these patients.

METHODS

In this systematic review, databases including PubMed, Web of Science, Scopus, Embase, Science Direct, and CINAHL were used. To ensure the quality of the studies and assess them for bias, we used the Methodological Index for Nonrandomized Studies scaling tool. The relevant data were extracted from the included studies and reported.

RESULTS

Twenty-five studies were included in our review based on the inclusion criteria. Age, socioeconomic status, education, and employment status; place of living and neighborhood; race and ethnicity; and insurance coverage were found to impact the outcomes and prognosis of PBTs.

CONCLUSION

Literature has shown correlations of various SDOH with the outcomes of PBTs. SDOH are not independent of each other; including and interpreting them in the process of decision making should be in a multifactorial and intercalated manner. We suggest prospective studies on finding the effect of inventing with SDOH through changes in health care policies, educating patients and care providers, improving socioeconomic conditions, and providing better insurance support, on the outcomes of PBTs.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

County Rurality is Associated with Increased Tumor Size and Decreased Survival in Patients with Ewing Sarcoma

Background

Ewing Sarcoma (ES) is an aggressive tumor affecting adolescents and young adults. Prior studies investigated the association between rurality and outcomes, although there is a paucity of literature focusing on ES.

Objective

This study aims to determine whether ES patients in rural areas are subject to adverse outcomes.

Methods

This study utilized the Surveillance, Epidemiology, and End Results (SEER) database. A Poisson regression model was used with controls for race, sex, median county income, and age to determine the association between rurality and tumor size. A multivariate Cox Proportional Hazard Model was utilized, controlling for age, race, gender, income, and tumor size.

Results

There were 868 patients eligible for analysis, with a mean age of 14.14 years. Of these patients, 97 lived in rural counties (11.18%). Metropolitan areas had a 9.50% smaller tumor size (p<0.0001), compared to non-metropolitan counties. Patients of Black race had a 14.32% larger tumor size (p<0.0001), and male sex was associated with a 15.34% larger tumor size (p<0.0001). The Cox Proportional Hazard model estimated that metropolitan areas had a 36% lower risk of death over time, compared to non-metropolitan areas (HR: 0.64, p ≤ 0.04).

Conclusion

Patients in metropolitan areas had a smaller tumor size at time of diagnosis and had a more favorable survival rate for cancer-specific mortality compared to patients residing in rural areas. Further work is needed to examine interventions to reduce this discrepancy and investigate the effect of extremely rural and urban settings and why racial disparities occur.

Formulation and validation of a baseline prognostic score for osteosarcoma treated uniformly with a non-high dose methotrexate-based protocol from a low middle income healthcare setting: a single centre analysis of 594 patients

Introduction

The outcomes of osteosarcoma in low middle income countries (LMICs) are different due to patients presenting in advanced stages, resource constraints and the use of non-high-dose-methotrexate (HDMTX)-based regimens. This study derived and validated a prognostic score for osteosarcoma that integrates biologic and social factors and is tailored for patients from an LMIC setting using a non-HDMTX-based protocol.

Materials and methods

A retrospective study including osteosarcoma patients enrolled for treatment at a single tertiary care centre in India between 2003-19 was conducted. Baseline biologic and social characteristics were extracted from medical records and survival outcomes were noted. The cohort was randomised into a derivation and validation cohort. Multivariable Cox regression was used to identify baseline characteristics that were independently prognostic for survival outcomes in the derivation cohort. A score was derived from the prognostic factors identified in the derivation cohort and further validated in the validation cohort with estimation of its predictive ability.

Results

594 patients with osteosarcoma were eligible for inclusion in the study. Around one-third of the cohort had metastatic disease with 59% of the patients residing in rural areas. The presence of metastases at baseline (HR 3.39; p<0.001; score=3), elevated serum alkaline phosphatase (SAP) >450 IU/L (HR 1.57; p=0.001; score=1) and baseline tumour size > 10 cm (HR 1.68; p<0.001; score=1) were identified to be independent factors predicting inferior event free survival (EFS) and were included in development of the prognostic score. Patients were categorized as low risk (score 0), intermediate risk (score 1-3) and high risk (4-5). Harrell's c-indices for the score were 0.682, 0.608 and 0.657 respectively for EFS in the derivation, validation and whole cohort respectively. The timed AUC of ROC was 0.67 for predicting 18-month EFS in the derivation, validation and whole cohorts while that for 36-month EFS were 0.68, 0.66 and 0.68 respectively.

Conclusions

The study describes the outcomes among osteosarcoma patients from an LMIC treated uniformly with a non-HDMTX-based protocol. Tumor size, baseline metastases and SAP were prognostic factors used to derive a score with good predictive value for survival outcomes. Social factors did not emerge as determinants of survival.

Breastfeeding, pregnancy, medicines, neurodevelopment, and population databases: the information desert

BACKGROUND

The pharmacoepidemiology of the long-term benefits and harms of medicines in pregnancy and breastfeeding has received little attention. The impact of maternal medicines on children is increasingly recognised as a source of avoidable harm. The focus of attention has expanded from congenital anomalies to include less visible, but equally important, outcomes, including cognition, neurodevelopmental disorders, educational performance, and childhood ill-health. Breastfeeding, whether as a source of medicine exposure, a mitigator of adverse effects or as an outcome, has been all but ignored in pharmacoepidemiology and pharmacovigilance: a significant 'blind spot'.

WHOLE-POPULATION DATA ON BREASTFEEDING

WHY WE NEED THEM: Optimal child development and maternal health necessitate breastfeeding, yet little information exists to guide families regarding the safety of medicine use during lactation. Breastfeeding initiation or success may be altered by medicine use, and breastfeeding may obscure the true relationship between medicine exposure during pregnancy and developmental outcomes. Absent or poorly standardised recording of breastfeeding in most population databases hampers analysis and understanding of the complex relationships between medicine, pregnancy, breastfeeding and infant and maternal health. The purpose of this paper is to present the arguments for breastfeeding to be included alongside medicine use and neurodevelopmental outcomes in whole-population database investigations of the harms and benefits of medicines during pregnancy, the puerperium and postnatal period. We review: 1) the current situation, 2) how these complexities might be accommodated in pharmacoepidemiological models, using antidepressants and antiepileptics as examples; 3) the challenges in obtaining comprehensive data.

CONCLUSIONS

The scarcity of whole-population data and the complexities of the inter-relationships between breastfeeding, medicines, co-exposures and infant outcomes are significant barriers to full characterisation of the benefits and harms of medicines during pregnancy and breastfeeding. This makes it difficult to answer the questions: 'is it safe to breastfeed whilst taking this medicine', and 'will this medicine interfere with breastfeeding and/ or infants' development'?

The Nomogram for Early Death in Patients with Bone and Soft Tissue Tumors

Objectives: The present study aimed to evaluate the early mortality rate and associated factors for early death in bone and soft tissue tumors, and to construct predictive nomogram. Methods: Patients diagnosed between 2010 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) dataset were enrolled. The early death (survival time ≤ 3 months) rate was calculated and associated risk factors were evaluated by the logistic regression models. The significant factors were used to construct predictive nomograms. Results: A total of 2,003 (8.5%) patients died within 3 months after cancer diagnosis, among whom 1,146 (4.9%) patients died from cancer-specific cause. Older age (19-50 and >50 years), grade (III and IV), reginal or distant stage were associated with higher odds of total, cancer-specific and non-cancer-specific early death. T2 stage, metastasis to brain and lung were risk factors for total and cancer-specific early death. Surgical interventions significantly decreased the odds of total, cancer-specific and non-cancer-specific early death. Female and black race were associated with lower odds of non-cancer-specific early death. The area under the curve (AUC) of the nomograms for total early death, cancer-specific and non-cancer-specific early death prediction was 88.0%, 89.0% and 83.2%, respectively. Conclusions: A total of 8.5% patients with bone and soft tissue tumors suffered early death. Several risk factors were associated with higher odds of early death while surgery can decrease the possibility of early death. Nomograms based on all related factors can be used to estimate the early death in bone and soft tissue tumors.

Incidence and mortality of bone cancer among children, adolescents and young adults of Brazil

OBJECTIVES

Bone cancers occur frequently in children, adolescents, and young adults aging 15 to 29 years. Osteosarcoma and Ewing sarcoma are the most frequent subtypes in this population. The aim of this study was to describe incidence and mortality trends of bone cancers among Brazilian children, adolescents and young adults.

METHODS

Incidence information was obtained from 23 population-based cancer registries. Mortality data were extracted from the Atlas of Cancer Mortality from 1979 to 2013. Specific and adjusted rates per million were analyzed according to gender, morphology and age at diagnosis. Median rates were used as a measure of central tendency. Joinpoint regression was applied to analyze trends.

RESULTS

Median incidence rates were 5.74 and 11.25 cases per million in children and young adults respectively. Osteosarcoma in the 15-19 years aged group had the highest incidence rates. Stable incidence rates were observed among five registries in 0-14 year's age group. Four registries had a decreased incidence trend among adolescents and young adults. Median mortality rates were 1.22 and 5.07 deaths per million in children and young adults respectively. Increased mortality was observed on the North and Northeast regions. Decreased mortality trends were seen in the South (children) and Southeast (adolescents and young adults).

CONCLUSION

Osteosarcoma and Ewing Sarcoma are the most incident bone cancers in all Brazilian regions. Bone cancers showed incidence and mortality patterns variation within the geographic regions and across age groups, although not significant. Despite limitations, it is crucial to monitor cancer epidemiology trends across geographic Brazilian regions.

Increased survival of patients aged 0-29 years with osteosarcoma: A period analysis, 1984-2013

Purpose

Osteosarcoma is the most common primary malignancy of bone, and typically occurs among children and adolescence. This study aims to evaluate treatment outcomes among children, adolescents and young adults with osteosarcoma over the three decades by the changes in the long‐term relative survival.

Methods

Osteosarcoma incidence and relative survival data from Surveillance, Epidemiology, and End Results (SEER) registries during 1984‐2013 were analyzed. The survival differences over three decades, age, sex, race, and socioeconomic status (SES) were assessed by comparing Kaplan‐Meier curves.

Results

The overall incidence of osteosarcoma kept relatively stable with 0.4 per 100 000 in the three decades with the peak incidence occurring in the aged 10‐19 group. The 10‐year relative survival rate (RSR) increased from 57.7% to 61.0% in the three decades, with the greatest increase in the aged 0‐9 group from 48.2% to 65.7%. The 10‐year RSR improved from 54.1% to 61.5% in males, and from 62.4% to 63.0% in females, respectively, in the three decades. Furthermore, survival dramatically improved from 30% to 60% in the high‐poverty group over the three decades.

Conclusion

This study demonstrated that the overall incidence of osteosarcoma remained stable, with an improvement in survival in the three decades. The improved survival was greater in males than in females in the three decades. Furthermore, the survival significantly increased in high‐poverty group, which was attributed to increasing improved health care system and patients with low finance can also have access to receiving effective and consistent treatment without distinction.