H. M. Dunlop2, B. Bende3, A. Kim1, J. L. Fisher4, V. P. Grignol1, C. M. Contreras1, S. Obeng-Gyasi1, T. M. Pawlik1, R. E. Pollock1, J. D. Beane1 1Ohio State University, Division Of Surgical Oncology, Columbus, OH, USA 2Ohio State University, College Of Medicine, Columbus, OH, USA 3Ohio State University, Department Of Biology, Columbus, OH, USA 4Ohio State University, College Of Public Health, Columbus, OH, USA
Introduction: Based on guidelines from the National Comprehensive Cancer Network (NCCN), treatment for extremity soft tissue sarcoma (ESTS) should include radiation therapy (RT) and surgical resection for tumors that are high grade and >5 cm. RT is time and labor-intensive for patients and requires significant expertise by the treating team. As such, this is often delivered at high-volume, tertiary medical centers, which may present a barrier to access for individuals with low socioeconomic status (SES). ??The aim of this study was to describe the association between SES, compliance with NCCN guidelines, and outcomes in patients with ESTS.
Methods: Patients with ESTS diagnosed from 2006 through 2018 were identified in the Survival, Epidemiology, and End Results database. The analytic cohort was restricted to patients with high grade tumors >5 cm in size without nodal or distant metastases who received surgery. The cohort was divided into quintiles based on the Yost index, a composite measure of socioeconomic status (SES) based on average educational level, median income, poverty rate, median housing value, median rent, unemployment rate, and employment mix of a given census tract. Stepwise multivariable logistic regression was used to examine the relationship between patient demographics, tumor characteristics, and receipt of radiation therapy. Adjusted accelerated failure time models were used to examine SES disparities in cancer-specific survival.
Results: There were 2,606 patients who met study criteria, with 27.9% (n=727) undergoing neoadjuvant RT, 46.0% (n=1198) undergoing adjuvant or intraoperative RT, and 25.4% (n=663) undergoing no RT. After adjusting for demographics and tumor characteristics, a lower SES was associated with lower likelihood of receiving RT (OR 0.72 [95% CI 0.59-0.88] p<0.001). Race and ethnicity were not significant predictors of receipt of RT or of disease recurrence. There was no difference in the sequencing of radiation therapy among SES groups (neoadjuvant vs. adjuvant). Low SES was associated with lower likelihood of disease recurrence (OR 0.74 [0.63-1.00], p<0.05) when adjusting for tumor characteristics and patient demographics but was associated with worse cancer-specific survival (HR 1.24 [1.07-1.44], p<0.005). Race and ethnicity were not significant predictors of cancer-specific survival in the fully adjusted model. Median survival time was 38 months (range: 0-155 months).
Conclusion: Patients with lower socioeconomic status are less likely to receive radiation therapy for extremity soft tissue sarcoma according to NCCN guidelines and cancer-specific survival is worse. These data support current efforts by our group to establish regional tumor boards involving clinicians both at academic medical centers and at community hospitals that see a large proportion of patients with low SES.