- Department of Neurologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
Rebecca A. Kasl
Department of Neurologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
DOI:10.4103/2152-7806.181985Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Kasl RA, Brinson PR, Chambless LB. Socioeconomic status does not affect prognosis in patients with glioblastoma multiforme. Surg Neurol Int 06-May-2016;7:
How to cite this URL: Kasl RA, Brinson PR, Chambless LB. Socioeconomic status does not affect prognosis in patients with glioblastoma multiforme. Surg Neurol Int 06-May-2016;7:. Available from: http://surgicalneurologyint.com/surgicalint_articles/socioeconomic-status-does-not-affect-prognosis-in-patients-with-glioblastoma-multiforme/
Background:Glioblastoma multiforme (GBM) is an aggressive malignancy, but there is marked heterogeneity in survival time. Health care disparities have demonstrated significance in oncologic outcomes but have not been clearly examined in this patient population. We investigated the role of sociodemographic variables in the prognosis of adult patients diagnosed with GBM.
Methods:This retrospective analysis included patients with a histologically confirmed diagnosis of GBM, who underwent resection or biopsy at a single institution from 2000 to 2014. Socioeconomic status (SES) was determined by household income according to the US Census zip code tabulation areas and the US national poverty level. Multivariate Cox proportional hazards analysis calculated effects on patient survival.
Results:Thirty percent of 218 subjects were of low SES, 57% mid, and 13% high. Low SES patients tended to be male (62%), Caucasian (92%), unmarried (91%), have dependents (100%), and limited to high school education (55%). SES did not predict insurance or employment status. SES was associated with marital status and number of cohabitants (P P = 0.0125), elderly patients (HR 1.70, P = 0.0158), and multifocal disease (HR 1.75, P = 0.0119). Longer prognosis was associated with gross total resection (HR 0.49, P = 0.0009), radiation therapy (HR 0.12, P P
Conclusions:SES alone does not predict prognosis in patients with newly diagnosed GBM. Sociodemographic variables such as old age, military service record, and insurance type may have a prognostication role.
Keywords: Brain tumor, glioblastoma multiforme, glioma, poverty, prognosis, socioeconomic status
Gliomas are the most common type of primary brain tumor.[
Socioeconomic status (SES) has been previously suggested to affect outcomes in a variety of malignancies.[
The zip code has been frequently used in US-based public health research as a proxy for SES.[
Using ZCTAs and government-sanctioned national poverty levels, we sought to assess the role of SES and other demographic variables in the prognosis of adult patients diagnosed with GBM.
We retrospectively analyzed patients with a histologically confirmed diagnosis of GBM, who underwent resection or biopsy at Vanderbilt University Medical Center from 2000 to 2014. Children and incarcerated patients were excluded from the study. Two hundred eighteen subjects were included. After approval from the Vanderbilt Institutional Review Board, data were extracted from electronic medical records and cataloged in the Research Electronic Data Capture database.[
To improve internal validity, zip codes were transformed into ZCTA codes in accordance with the 2012 United States Census.[
All data were de-identified before statistical analysis in Microsoft Excel (Microsoft. Redmond, Washington)[
The 218 study subjects were stratified according to their income-based socioeconomic profile [
SES predicted marital status (P = 0.0003), number of cohabitants (P < 0.0001), and level of education attained (P = 0.0485). Our institution makes a concentrated effort to provide healthcare to the underserved, and most patients in this study were of low SES (47%). There was no statistical different in race, age, or sex across SES. Low SES patients were more likely to be unmarried, live with at least 1 other person in their home, and have less than or equal to a high school education. SES did not predict presence of insurance or employment status. Low SES patients were not more likely to have Medicaid insurance.
All patients had a histologically confirmed diagnosis of Grade IV astrocytoma. Multifocal disease presentation was uncommon (16%). Most patients (61%) received near total resection or subtotal resection. Extent of resection, KPS, clinical trial enrollment, and type of treatment received were not predicted by SES. Overall patient functional status pre- and post-operatively was high. The preoperative and postoperative KPS scores were at least 70 in 85% and 88% of patients, respectively. Seventy-five percent received TMZ according to the Stupp protocol, and 87% were treated with XRT.
Univariate Cox proportional hazards analysis yielded 12 variables with P < 0.10 to meet inclusion criteria for the multivariate analysis [
With the rising costs of healthcare and increasing incidence of cancer, oncology patients make up a significant component of the national disease burden in the United States. A patient's ability to access and afford treatment is affected by their social situation and economic resources. In the oncology setting, research calls into question the impact of SES on overall survival after a diagnosis of cancer.[
Sociodemographic variables are relevant to both the developing and developed world. They have an established role in many different types of malignancies and various stages throughout the disease course.[
Race is a frequently studied demographic variable in oncology. African-American patients have decreased overall survival in non-central nervous system (CNS) adult and pediatric malignancies compared to their Caucasian counterparts.[
Socioeconomic data specific to CNS malignancy incidence and outcomes have yielded mixed results.[
ZCTA codes served as a useful representation of income and proxy for SES in our study. Other studies in and outside of neurosurgery have used zip codes as an SES marker as well.[
Patient resources were further analyzed in our study of military background and insurance status at the time of diagnosis. While lack of insurance did not affect prognosis, a patient's insurance type was statistically significant in the multivariate model [
Glioblastoma has been studied extensively in search of predictors separating the short from long-term survivors. No factor has been found to more strongly affect tumor prognosis than the addition of TMZ to XRT since the 2005 Stupp trial;[
We disproved our hypothesis and found SES to not be associated with GBM prognosis in a sample size whose demographics were similar to the local population. This is notably different from several other malignancies; in which, authors have presented a prognostic role for sociodemographic variables.[
In our US-based study using ZCTA codes as a proxy for SES, we present new data demonstrating that SES does not affect GBM prognosis. However, sociodemographic variables such as a military service record and insurance type have a suggested prognostication role. Consistent with prior studies, old age, multifocal tumors, XRT, and chemotherapy affected outcomes. XRT has the largest impact on median survival time. Although a small, single-institution, retrospective study, this research presents a formative opportunity for physicians to consider a patient's socioeconomic profile when treating GBM.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The authors would like to thank Travis Ladner and Dr. Edmond Kabagambe for their assistance with the statistical analysis.
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