Associations of Social and Demographic Factors on the Outcomes of Ocular Melanoma and Other Adult Ocular Neoplasms in the United States: A Systematic Review

Introduction

Social determinants of health (SDOH), including economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context, shape gaps in health outcomes across many conditions. Ocular neoplasms are no exception. Cancers such as uveal melanoma, conjunctival squamous cell carcinoma, ocular lymphoma, and ocular Kaposi sarcoma may be especially vulnerable to social and demographic influences. We systematically reviewed documented associations between SDOH and these ocular cancers in the United States.

Methods

Following a pre-registered protocol, we searched MEDLINE, Embase, and Web of Science (from January 2000 to November 2023) for primary studies of any design that evaluated one or more relationships between SDOH and outcomes related to the ocular cancers listed above. Outcomes included cancer incidence, stage at diagnosis, treatment patterns, survival, and mortality. We extracted study design, population, exposure, and outcome characteristics, classified each exposure-outcome association by its direction (e.g., favorable, unfavorable, or null), and assessed the risk of bias using a modified Newcastle-Ottawa Scale. Due to heterogeneity in exposure and outcome definitions, we narratively synthesized findings by SDOH domain.

Results

We included 21 studies examining 167 unique associations. Social and community context, typically represented as race and ethnicity, was the most frequently studied domain, followed by economic stability (e.g., income) and healthcare access and quality (e.g., insurance type or travel distance). Across domains, lower socioeconomic status, public or no insurance, minority racial and ethnic identity, and care at academic centers generally are associated with later stage at diagnosis, higher odds of enucleation, or worse survival. Higher income, private insurance, and treatment at experienced facilities were often associated to earlier presentation and better outcomes.

Conclusion

SDOH have a measurable and often unfavorable relationship with the diagnosis, management, and prognosis of rare adult ocular cancers in the United States. Standardized SDOH exposures and measurements, prospective data collection, and adjustment for confounding are necessary to strengthen the evidence and guide multi-domain interventions (e.g., expanded insurance, travel assistance to high-volume centers, and community eye-health initiatives) aimed at narrowing these gaps.