不同富裕程度的小儿骨肉瘤患者接受的治疗是否不同?一家医疗机构的经验。

IF 4.2 2区 医学 Q1 ORTHOPEDICS
David Kell, Daniel Yang, Juliana Lee, Kevin Orellana, Sarah Wetzl, Alexandre Arkader
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引用次数: 0

摘要

背景:已发表的研究社会经济因素及其与骨肉瘤发病和治疗关系的报告表明,社会经济地位较低与化疗反应较差和存活率较低之间存在关联。然而,这些差异背后的驱动因素尚不清楚。儿童机会指数由diversitydatakids.org(https://www.diversitydatakids.org/)于2014年开发,旨在通过一个专门针对儿科人群并按人口普查区组织的指数来累积量化健康的社会决定因素。儿童机会指数可用于探索患者的社会经济背景与骨肉瘤的发病、治疗和预后差异之间的关系:儿童机会指数得分的差异是否与以下方面的差异有关:(1)从症状出现到首次就诊骨肉瘤的时间;(2)化疗时机或手术切除的时机和类型;或(3)最初的疾病严重程度、转移性疾病的发展或总生存期?我们利用美国大西洋中部地区一家大型儿科三级癌症中心 2006 年至 2022 年的机构记录数据,开展了一项回顾性治疗研究。我们的主要医疗机构位于城市环境中,公共交通四通八达。如果患者寻求第二意见或本机构不是骨科治疗的主要地点(24% [223 例中的 54 例])、电子病历不完整(4% [223 例中的 9 例])、居住在国际国家(3% [223 例中的 7 例])、复发后就诊(3% [223 例中的 7 例])或在本机构缺乏 2 年随访(2% [223 例中的 4 例]),则不纳入分析。共有 113 名儿童患者(18 岁以下儿童)符合纳入标准。儿童机会指数是一个综合指数,由三个领域(教育、健康与环境、社会与经济)和领域内的 29 个指标组成,用于反映差异对儿童福祉的累积影响。全国儿童机会指数的得分从 1 分到 100 分不等。每个分数代表美国 18 岁或以下儿童人口的同等比例。数字越大,表示社会经济机会越多。童年机会指数的总分被分成三个组,分别代表儿童的相对社会经济机会:得分小于 34 分的为最低三等分组,得分介于 34 分至 66 分的为中间三等分组,得分大于 66 分的为最高三等分组。平均值、范围、中位数、IQRs 和百分比用于描述研究样本。对三个组别(最低三分位数、中间值和最高值)进行数据分析,评估发病时间、治疗变化、疾病严重程度和总体存活率的差异。在比较分类变量时采用了卡方检验和费雪精确检验。Mann-Whitney U 检验比较连续数据。卡普兰-梅耶尔生存分析按童年机会指数三等分层,评估转移性疾病的发展和总体存活率,为期5年。采用对数秩检验来评估统计学意义。由于样本量较小,我们无法控制种族和保险等潜在混杂因素。不过,童年机会指数数据所包含的三个领域(教育、健康与环境、社会与经济)间接解释了与种族和保险状况有关的差异:较低的社会经济机会水平与较低的社会经济机会水平之间没有关联,这体现在儿童机会指数三等分之间从症状出现到首次就诊的时间间隔没有差异(平均值±标准差,最低三等分 77 ± 67 天[95% 置信区间 (CI) 60 至 94],中间三等分 69 ± 94 天[95% CI 50 至 89],最高三等分 56 ± 58 天[95% CI 41 至 71];P = 0.3)。同样,我们发现社会经济机会水平较低与从首次就诊到首次化疗的时间(最低三等分 19 ± 12 天 [95% CI 12 至 26],中间 19 ± 14 天 [95% CI 11 至 26],最高 15 ± 9.7 天 [95% CI 8.4 至 21])之间没有关联,儿童机会指数三等分之间没有差异;P = 0.31。31)、手术切除时间(最低三等分 99 ± 35 天 [95% CI 87 至 111],中间 88 ± 28 天 [95% CI 77 至 99],最高 102 ± 64 天 [95% CI 86 至 118];P = 0.24),或手术切除类型(保肢与截肢:最低三等分中 84% [25 人中的 21 人]、中间三等分中 83% [29 人中的 24 人]、最高三等分中 81% [59 人中的 48 人] 接受了保肢手术;P = 0.52)。最后,我们发现 5 年无病生存率没有差异(最低三等分 27% [95% CI 7.
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Do Patients of Different Levels of Affluence Receive Different Care for Pediatric Osteosarcomas? One Institution's Experience.

Background: The published reports examining socioeconomic factors and their relationship to osteosarcoma presentation and treatment suggest an association between lower socioeconomic status and a worse response to chemotherapy and lower survivorship. However, the driving factors behind these disparities are unclear. The Child Opportunity Index was developed by diversitydatakids.org (https://www.diversitydatakids.org/) in 2014 to cumulatively quantify social determinants of health in an index specifically tailored toward a pediatric population and organized by census tract. The Childhood Opportunity Index can be used to explore the relationship between a patient's socioeconomic background and disparities in osteosarcoma presentation, treatment, and outcomes.

Question/purposes: Are differences in a child's Childhood Opportunity Index score associated with differences in (1) time from symptom onset to first office visit for osteosarcoma, (2) timing of chemotherapy or timing and type of surgical resection, or (3) initial disease severity, development of metastatic disease, or overall survival?

Methods: A retrospective therapeutic study was conducted using data drawn from the institutional records of a large pediatric tertiary cancer center located in the Mid-Atlantic region of the United States from the years 2006 to 2022. Our main site is in an urban setting, with ample access to public transit. Patients were excluded from analysis if they were seeking a second opinion or our institution was not the main point of orthopaedic care (24% [54 of 223]), had incomplete electronic medical records (4% [9 of 223]), resided in an international country (3% [7 of 223]), presented after relapse (3% [7 of 223]), or lacked 2 years of follow-up at our institution (2% [4 of 223]). A total of 113 pediatric patients (children younger than 18 years) met the inclusion criteria. The Child Opportunity Index is a composite index derived from three domains (education, health and environment, and social and economic) and 29 indicators within the domains that serve to capture the cumulative effect of disparities on child well-being. National Childhood Opportunity scores were collected and scored from 1 to 100. Each score represents an equal proportion of the US population of children 18 years of age or younger. A higher number indicates higher levels of socioeconomic opportunity. The overall Childhood Opportunity Index score was then broken down into three groups representative of the child's relative socioeconomic opportunity: lowest tertile for scores < 34, middle tertile for scores between 34 and 66, and highest tertile for scores > 66. Means, ranges, medians, IQRs, and percentages were used to describe the study sample. Data analysis was conducted across the three groups (lowest tertile, middle, and highest), assessing differences in time to presentation, treatment variations, disease severity, and overall survivorship. Chi-square and Fisher exact tests were applied to compare categorical variables. Mann-Whitney U tests compared continuous data. Kaplan-Meier survival analysis, stratified by Childhood Opportunity Index tertile, was performed for a 5-year period to evaluate the development of metastatic disease and overall survivorship. A log-rank test was applied to evaluate statistical significance. Due to the small sample size, we were unable to control potential confounders such as race and insurance. However, the three domains (education, health and environment, and social and economic) encapsulated by the Childhood Opportunity Index data indirectly account for disparities related to race and insurance status.

Results: There was no association between lower levels of socioeconomic opportunity, as expressed by the lack of difference between the Childhood Opportunity Index tertiles for the interval between symptom onset and first office visit (mean ± SD lowest tertile 77 ± 67 days [95% confidence interval (CI) 60 to 94], middle tertile 69 ± 94 days [95% CI 50 to 89], and highest tertile 56 ± 58 days [95% CI 41 to 71]; p = 0.3). Similarly, we found no association between lower levels of socioeconomic opportunity, as expressed by the lack of difference between the Childhood Opportunity Index tertiles and the time elapsed from the first office visit to the first chemotherapy session (lowest tertile 19 ± 12 days [95% CI 12 to 26], middle 19 ± 14 days [95% CI 11 to 26], and highest 15 ± 9.7 days [95% CI 8.4 to 21]; p = 0.31), the time to surgical resection (lowest tertile 99 ± 35 days [95% CI 87 to 111], middle 88 ± 28 days [95% CI 77 to 99], and highest 102 ± 64 days [95% CI 86 to 118]; p = 0.24), or the type of surgical resection (limb-sparing versus amputation: 84% [21 of 25] in lowest tertile, 83% [24 of 29] in the middle tertile, and 81% [48 of 59] in the highest tertile received limb-sparing surgery; p = 0.52). Finally, we found no differences in terms of disease-free survival at 5 years (lowest tertile 27% [95% CI 7.8% to 43%], middle 44% [95% CI 23% to 59%], and highest 56% [95% CI 40% to 67%]; p = 0.22), overall survival (lowest 74% [95% CI 58% to 95%], middle 82% [95% CI 68% to 98%], and highest 64% [95% CI 52% to 78%]; p = 0.27), or in terms of survivorship of the cohort, excluding patients who presented with metastatic disease (lowest 84% [95% CI 68% to 100%], middle 91% [95% CI 80% to 100%], and highest 68% [95% CI 55% to 83%]; p = 0.10).

Conclusion: In our single-center retrospective study of 113 children who presented with osteosarcoma, we did not find an association between a patient's national socioeconomic opportunity and their time to presentation, chemotherapy treatment, time to and type of surgical resection, or disease-free and overall survival. Prior work has shown an association between socioeconomic background and disparities in osteosarcoma treatment. It is possible that these findings will be similar to those from other hospitals and geographic areas, but based on our findings, we believe that proximity to providers, access to public transit, and regional insurance policies may help diminish these disparities. Future multicenter studies are needed to further explore the role that regional variations and the aforementioned factors may play in osteosarcoma treatment to help inform the direction of public policy.

Level of evidence: Level III, therapeutic study.

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来源期刊
CiteScore
7.00
自引率
11.90%
发文量
722
审稿时长
2.5 months
期刊介绍: Clinical Orthopaedics and Related Research® is a leading peer-reviewed journal devoted to the dissemination of new and important orthopaedic knowledge. CORR® brings readers the latest clinical and basic research, along with columns, commentaries, and interviews with authors.
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