Identifying Disparities in Care in Treating Glioblastoma: A Retrospective Cohort Study of Patients Treated at a Safety-net Versus Private Hospital Setting

The association of neighborhood-level deprivation with glioblastoma outcomes: a single center cohort study

Glioblastoma is the most common primary brain malignancy. Though literature has suggested the association of glioblastoma outcomes and socioeconomic status, there is limited evidence regarding the association of neighborhood-level socioeconomic deprivation on glioblastoma outcomes. The aim of this study was to assess the impact of neighborhood-level socioeconomic deprivation on glioblastoma survival. We retrospectively reviewed all adult glioblastoma patients seen at a single institution from 2008 to 2023. Neighborhood deprivation was assessed via Area Deprivation Index (ADI), with higher ADI indicating greater neighborhood socioeconomic disadvantage. Log-rank tests and multivariate cox regression was used to assess the effect of ADI and other socioeconomic variables while controlling for a priori selected clinical variables with known relevance to survival. In total, 1464 patients met inclusion criteria. The average age at diagnosis was 60 ± 14 years with a median overall survival of 13.8 months (IQR 13-14.8). The median ADI of the cohort was 66(IQR 46-84). Patients with high neighborhood disadvantage had worse overall survival compared to patients with those without (11.7 vs. 14.8 months, p =.001). In the multivariable model, patients with high neighborhood disadvantage had worse overall survival (HR 1.25, 95%CI 1.09-1.43). To account for changes in WHO guidelines, we implemented the model on patients diagnosed between 2017 and 2023 and findings were consistent (HR 1.26,95%CI 1.01-1.56). We report the first study demonstrating glioblastoma patients with higher neighborhood deprivation have worse survival after controlling for other socioeconomic and biomolecular markers. Neighborhood socioeconomic status may be a prognostic marker for glioblastoma survival.

The Association of Neighborhood-Level Deprivation with Glioblastoma Outcomes: A Single Center Cohort Study

Purpose

Glioblastoma is the most common primary brain malignancy. Though literature has suggested the association of glioblastoma outcomes and socioeconomic status, there is limited evidence regarding the association of neighborhood-level socioeconomic deprivation on glioblastoma outcomes. The aim of this study was to assess the impact of neighborhood-level socioeconomic deprivation on glioblastoma survival.

Methods

We retrospectively reviewed all adult glioblastoma patients seen at a single institution from 2008 to 2023. Neighborhood deprivation was assessed via Area Deprivation Index (ADI), with higher ADI indicating greater neighborhood socioeconomic deprivation. Log-rank tests and multivariate cox regression was used to assess the effect of ADI and other socioeconomic variables while controlling for a priori selected clinical variables with known relevance to survival.

Results

In total, 1464 patients met inclusion criteria. The average age at diagnosis was 60 ± 14 years with a median overall survival of 13.8 months (IQR 13-14.8). The median ADI of the cohort was 66(IQR 46-84). Patients with high ADI had worse overall survival compared to patients with low ADI (11.7 vs 14.8 months, p=.001). In the multivariable model, patients with high ADI had worse overall survival (HR 1.25, 95%CI 1.09-1.43). To account for changes in WHO guidelines, we implemented the model on patients diagnosed between 2017-2023 and findings were consistent (HR 1.26,95%CI 1.01-1.56).

Conclusion

We report the first study demonstrating glioblastoma patients with higher neighborhood deprivation have worse survival after controlling for other socioeconomic and biomolecular markers. Neighborhood socioeconomic status may be a prognostic marker for glioblastoma survival.

Patients with glioblastoma: A tale of health care access and genetic ancestry

The incidence of glioblastoma, previously described as a disease predominantly affecting non‐Hispanic White patients, was higher among non‐White patients in the authors' recent study in which the racial/ethnical composition of the patients was representative of the overall population. These findings offer an opportunity to accurately redefine the patient population of patients with glioblastoma bearing the burden of this disease in the United States.

Economic income and survival in patients affected by glioblastoma: A systematic review and meta-analysis

Background

Within socioeconomic variables, economic income has been associated with the prognosis of patients with glioblastoma. However, studies investigating this issue provided conflicting results.

Methods

We carried out a systematic review and meta-analysis of studies investigating the correlation between economic income and survival in patients with glioblastoma. The inverse variance technique for hazard ratio (HR) assessment has been employed in reporting the random effect model.

Results

We included 12 studies for a total of 143 303 GBM patients (67 463 with high economic income, and 25 679 with low economic income). In the overall analysis, lower economic income resulted in poorer survival (pooled HR 1.09, 95% CI: 1.02-1.17, I2 = 64%). Variables like the type of Health Care System (public, private, or mixed) and the time in which patients have been treated (pre or post-EORTC-NCIC trial 22981/26981, CE.3 protocol advent) did not modify survival on pooled analysis.

Conclusions

Economic conditions and income influence the prognosis of patients with glioblastoma. A better understanding of the modifiable barriers leading to treatment disparities in more disadvantaged patients is warranted to make equal oncological care.

National Trends and Factors Associated with Voluntary Refusal of Glioblastoma Treatment: A Retrospective Review of the National Cancer Database

OBJECTIVE

Adherence to combinatorial treatments are important predictors of improved long-term outcomes for patients with glioblastoma (GB); however, factors associated with refusal of surgery, chemotherapy, or radiotherapy (RT) by patients with GB have not been studied.

METHODS

The National Cancer Database was queried from 2004 to 2018 to identify patients with a primary diagnosis of GB who underwent surgical resection alone or followed by either RT or chemotherapy. Adult patients who voluntarily rejected a physician's recommendations for 1 or more treatment were selected. Multivariable regression was used to identify factors associated with rejection of surgical resection, chemotherapy, and RT. Patients receiving treatment were 3:1 propensity score matched to those rejecting treatment and median overall survival (OS) was compared.

RESULTS

58,788 patients were included in the analysis. Factors associated with voluntary refusal of GB treatment included: old age, nonprivate insurance, female sex, Black race, comorbidities, treatment at a nonacademic facility, and living 55+ miles away from a treatment facility (P < 0.05). On propensity matched analysis, refusal of surgery conferred a 4 month decrease in OS (P < 0.001), RT an 8 month decrease in OS (P < 0.001), and chemotherapy a 7 month decrease in OS (P < 0.001).

CONCLUSIONS

In patients with GB, age, sex, race, nonprivate insurance, medical comorbidities, distance from treatment facility, and geographic location were associated with refusal of surgery, postsurgical RT, and chemotherapy. In addition, treatment refusal had a significant impact on OS length.

Molecular Targeted Therapies in Glioblastoma Multiforme: A Systematic Overview of Global Trends and Findings

This systematic review assesses current molecular targeted therapies for glioblastoma multiforme (GBM), a challenging condition with limited treatment options. Using PRISMA methodology, 166 eligible studies, involving 2526 patients (61.49% male, 38.51% female, with a male-to-female ratio of 1.59/1), were analyzed. In laboratory studies, 52.52% primarily used human glioblastoma cell cultures (HCC), and 43.17% employed animal samples (mainly mice). Clinical participants ranged from 18 to 100 years, with 60.2% using combined therapies and 39.8% monotherapies. Mechanistic categories included Protein Kinase Phosphorylation (41.6%), Cell Cycle-Related Mechanisms (18.1%), Microenvironmental Targets (19.9%), Immunological Targets (4.2%), and Other Mechanisms (16.3%). Key molecular targets included Epidermal Growth Factor Receptor (EGFR) (10.8%), Mammalian Target of Rapamycin (mTOR) (7.2%), Vascular Endothelial Growth Factor (VEGF) (6.6%), and Mitogen-Activated Protein Kinase (MEK) (5.4%). This review provides a comprehensive assessment of molecular therapies for GBM, highlighting their varied efficacy in clinical and laboratory settings, ultimately impacting overall and progression-free survival in GBM management.

Area-level socioeconomic status is positively correlated with glioblastoma incidence and prognosis in the United States

In the United States, an individual’s access to resources, insurance status, and wealth are critical social determinants that affect both the risk and outcomes of many diseases. One disease for which the correlation with socioeconomic status (SES) is less well-characterized is glioblastoma (GBM), a devastating brain malignancy. The aim of this study was to review the current literature characterizing the relationship between area-level SES and both GBM incidence and prognosis in the United States. A query of multiple databases was performed to identify the existing data on SES and GBM incidence or prognosis. Papers were filtered by relevant terms and topics. A narrative review was then constructed to summarize the current body of knowledge on this topic. We obtained a total of three papers that analyze SES and GBM incidence, which all report a positive correlation between area-level SES and GBM incidence. In addition, we found 14 papers that focus on SES and GBM prognosis, either overall survival or GBM-specific survival. Those studies that analyze data from greater than 1,530 patients report a positive correlation between area-level SES and individual prognosis, while those with smaller study populations report no significant relationship. Our report underlines the strong association between SES and GBM incidence and highlights the need for large study populations to assess SES and GBM prognosis to ideally guide interventions that improve outcomes. Further studies are needed to determine underlying socio-economic stresses on GBM risk and outcomes to identify opportunities for intervention.

Effects of postoperative radiotherapy and docetaxel and PD-1 inhibitors on the survival and safety of glioblastoma patients: a systematic review and meta-analysis

Background

The present standard treatment rarely allows the complete removal of glioblastoma (GBM). So postoperative treatments are provided to prevent or delay tumor recurrence. The overall survival (OS) rate and safety of postoperative chemotherapy alone, or combined with radiotherapy (RT), or programmed cell death-1 (PD-1) inhibitor in GBM is still unclear. The present goal was to explore postoperative treatment's effect on the survival and safety of patients with GBM.

Methods

We searched the mainstream online databases for clinical studies of RT and chemotherapy and PD-1 inhibitors in the treatment of GBM published up to May 2020. The patients in the experimental group accepted an anti-PD-1 drug alone and RT + chemotherapy, whereas the controlled patients were treated with docetaxel alone. The literature qualities were assessed using Cochrane Risk of Bias 2.0, and studies were assigned. The meta-analysis was conducted by RevMan 5.4 software.

Results

A total of 927 articles were identified through the online database search. The articles unable to meet the inclusion criteria were excluded leaving 6 studies for inclusion in the study. Compared with docetaxel-based chemotherapy for GBM, combined RT chemotherapy and PD-1 inhibitor therapy had better OS [mean difference (MD), -1.75; 95% confidence interval (CI): -2.99 to -0.51; P=0.006] and progression-free survival (PFS) and a lower incidence of adverse reactions (MD, -7.03; 95% CI: -7.64 to -6.42; P<0.00001) above grade III.

Conclusions

Postoperative combination of RT and chemotherapy and PD-1 inhibitors had some advantages over docetaxel in terms of effectiveness. More clinical trials are needed to confirm effectiveness.

Surgical Management of a Massive Frontal Bone Hemangioma: Case Report

Intraosseous hemangiomas are rare, benign tumors that can arise from the calvarium. These lesions often invade the outer table of the skull, but typically spare the inner table and intracranial structures. En bloc surgical resection is the standard treatment for intraosseous hemangiomas. However, a piecemeal resection may be required to safely remove the tumor in cases involving the inner table to protect the underlying brain parenchyma and vascular structures. Proper reconstruction is critical to optimize the cosmetic outcome, and a staged procedure allowing implantation of a custom-made implant can be considered for large lesions involving the forehead. We present a case of a patient with a large frontal intraosseous hemangioma with intradural involvement to highlight the surgical nuances of resection and review the existing literature regarding optimal management of these patients.

Oral cancer patients achieve comparable survival at high safety-net burden hospitals

PURPOSE

To evaluate the impact of hospital safety-net burden and social demographics on the overall survival of patients with oral cavity squamous cell carcinoma.

MATERIALS AND METHODS

We identified 48,176 oral cancer patients diagnosed between the years 2004 to 2015 from the National Cancer Database and categorized treatment facilities as no, low, or high safety-net burden hospitals based on the percentage of uninsured or Medicaid patients treated. Using the Kaplan Meier method and multivariate analysis, we examined the effect of hospital safety-net burden, sociodemographic variables, and clinical factors on overall survival.

RESULTS

Of the 1269 treatment facilities assessed, the median percentage of uninsured/Medicaid patients treated was 0% at no, 11.6% at low, and 23.5% at high safety-net burden hospitals and median survival was 68.6, 74.8, and 55.0 months, respectively (p < 0.0001). High safety-net burden hospitals treated more non-white populations (15.4%), lower median household income (<$30,000) (23.2%), and advanced stage cancers (AJCC III/IV) (54.6%). Patients treated at low (aHR = 0.97; 95% CI = 0.91-1.04, p = 0.405) and high (aHR = 1.05; 95% CI = 0.98-1.13, p = 0.175) safety-net burden hospitals did not experience worse survival outcomes compared to patients treated at no safety-net burden hospitals.

CONCLUSION

High safety-net burden hospitals treated more oral cancer patients of lower socioeconomic status and advanced disease. Multivariate analysis showed high safety-net burden hospitals achieved comparable patient survival to lower burden hospitals.

Socioeconomic factors affecting survivorship of glioblastoma patients in the Philippines

Glioblastoma (GBM) is the most common malignant primary brain tumor in adults worldwide. However, data on the survivorship of GBM patients in low- and middle-income countries is sparse. We determined whether socioeconomic factors such as marital status, place of residence, educational attainment, employment status, and income affected survival. A retrospective cohort study of surgically managed GBM patients (n = 48) in a single center over a five-year period was conducted using chart review and telephone interview. The mean age was 41 years, with a male predilection (62%). Most patients were married (73%), employed full time (79%), resided in a rural location (56%), completed secondary education (44%), and had a low income (83%). Most of the tumors were > 5 cm at the time of diagnosis (90%) and involved more than one lobe (40%). Majority underwent subtotal resection (56%). Only 15% (n = 7) had adjuvant chemoradiation while 23% (n = 11) had radiotherapy alone. Median overall survival was 7.6 months. Multivariate analysis showed that extent of resection (gross total resection, p = 0.0033; subtotal resection, p = 0.0069) and adjuvant treatment (p = 0.0254) were associated with improved survival, while low income (p = 0.0178) and educational (p = 0.0206) levels and part-time employment (p = 0.0063) were associated with decreased survival. Many GBM patients at our center presented at an advanced stage in their natural history, and majority (62%) did not receive adjuvant treatment after surgery. As such, the median overall survival was less than that reported in developed countries. Of the socioeconomic factors analyzed, low income and educational levels and part-time employment were negatively associated with survivorship.

Overcoming Barriers to Radiation Oncology Access in Low-Resource Settings in the United States

Providing high-quality radiation therapy in medically underserved, low-resource environments can be challenging in the United States. During the American Society of Radiation Oncology 2020 Annual Meeting, the American Society for Radiation Oncology Committee on Health Equity, Diversity, and Inclusion hosted 4 radiation oncologists from both academic and community practices in an educational session. Speakers discussed creative ways to overcome barriers to equitable cancer care and outcomes for their vulnerable patient populations in both rural and urban settings. Successful tactics have included applying for state-sponsored grants, lobbying hospital leadership for equipment upgrades, implementing quality improvement programs specifically targeting the needs of the patient population, studying novel hypofractionation schedules, monitoring toxicities using wearable devices, and expanding transportation options.

Racial/ethnic disparities in treatment pattern and time to treatment for adults with glioblastoma in the US

PURPOSE

Race/ethnicity have been previously shown to significantly affect survival after diagnosis with glioblastoma, but the cause of this survival difference is not known. The aim of this study was to examine variation in treatment pattern and time to treatment by race/ethnicity, and the extent to which this affects survival.

METHODS

Data were obtained from the National Cancer Database (NCDB) for adults ≥ 40 with glioblastoma from 2004 to 2016 (N = 68,979). Treatment patterns and time to treatment by race/ethnicity were compared using univariable and multivariable logistic and linear regression models, respectively, and adjusted for known prognostic factors and factors potentially affecting health care access.

RESULTS

Black non-Hispanics (BNH) and Hispanics were less likely to receive radiation and less likely to receive chemotherapy as compared to White non-Hispanics (WNH). Time to radiation initiation was ~ 2 days longer and time to chemotherapy initiation was ~ 4 days longer in both groups in comparison to WNH.

CONCLUSION

Both race/ethnicity and treatment timing significantly affected survival time, and this association remained after adjustment for known prognostic factors. Additional research is necessary to disentangle the specific causal factors, and the mechanism with which they affect survival.