Elsevier

The Lancet

Volume 400, Issue 10368, 10–16 December 2022, Pages 2063-2073
The Lancet

Articles
Racial disparities in recommendations for surgical resection of primary brain tumours: a registry-based cohort analysis

https://doi.org/10.1016/S0140-6736(22)00839-XGet rights and content

Summary

Background

Disparities in treatment and outcomes disproportionately affect minority ethnic and racial populations in many surgical fields. Although substantial research in racial disparities has focused on outcomes, little is known about how surgeon recommendations can be influenced by patient race. The aim of this study was to investigate racial and socioeconomic disparities in the surgical management of primary brain tumors.

Methods

In this registry-based cohort study, we used data from the Surveillance, Epidemiology, and End Results (SEER) database (1975–2016) and the American College of Surgeons National Cancer Database (NCDB) in the USA for independent analysis. Adults (aged ≥20 years) with a new diagnosis of meningioma, glioblastoma, pituitary adenoma, vestibular schwannoma, astrocytoma, and oligodendroglioma, with information on tumour size and surgical recommendation were included in the analysis. The primary outcome of this study was the odds of a surgeon recommending against surgical resection at diagnosis of primary brain neoplasms. This outcome was determined using multivariable logistic regression with clinical, demographic, and socioeconomic factors.

Findings

This study included US national data from the SEER (1975–2016) and NCDB (2004–17) databases of adults with a new diagnosis of meningioma (SEER n=63 674; NCDB n=222 673), glioblastoma (n=35 258; n=104 047), pituitary adenoma (n=27 506; n=87 772), vestibular schwannoma (n=11 525; n=30 745), astrocytoma (n=5402; n=10 631), and oligodendroglioma (n=3977; n=9187). Independent of clinical and demographic factors, including insurance status and rural–urban continuum code, Black patients had significantly higher odds of recommendation against surgical resection of meningioma (adjusted odds ratio 1·13, 95% CI 1·06–1·21, p<0·0001), glioblastoma (1·14, 1·01–1·28, p=0·038), pituitary adenoma (1·13, 1·05–1·22, p<0·0001), and vestibular schwannoma (1·48, 1·19–1·84, p<0·0001) when compared with White patients in the SEER dataset. Additionally, patients of unknown race had significantly higher odds of recommendation against surgical resection for pituitary adenoma (1·80, 1·41–2·30, p<0·0001) and vestibular schwannoma (1·49, 1·10–2·04, p=0·011). Performing a validation analysis using the NCDB dataset confirmed these significant results for Black patients with meningioma (1·18, 1·14–1·22, p<0·0001), glioblastoma (1·19, 1·12–1·28, p<0·0001), pituitary adenoma (1·21, 1·16–1·25, p<0·0001), and vestibular schwannoma (1·19, 1·04–1·35, p=0·0085), and indicated and indicated that the findings are independent of patient comorbidities. When further restricted to the most recent decade in SEER, these inequities held true for Black patients, except those with glioblastoma (meningioma [1·18, 1·08–1·28, p<0·0001], pituitary adenoma [1·20, 1·09–1·31, p<0·0001], and vestibular schwannoma [1·54, 1·16–2·04, p=0·0031]).

Interpretation

Racial disparities in surgery recommendations in the USA exist for patients with primary brain tumours, independent of potential confounders including clinical, demographic, and select socioeconomic factors. Further studies are needed to understand drivers of this bias and enhance equality in surgical care.

Funding

None.

Introduction

Racial disparities in health care have persisted since the beginning of modern medicine, from the Tuskegee syphilis studies in 1932 to continued racial divides in all-cause mortality rates, hospital complications, and cancer survival in the modern era.1, 2, 3 Multiple contributions to inequality exist along a patient's health-care trajectory including access, affordability, and the patient–physician relationship. Inequity in surgical care is commonly attributed to patient-specific factors (eg, race, insurance, and socioeconomic status), systemic factors (eg, facility resources and experience), and provider-specific factors (eg, implicit bias).4 Research into the role of implicit bias (unconscious assumptions of groups of individuals) in surgical decision making has been growing but remains challenging, due in part to the difficulty in its measurement and in isolating its effect from socioeconomic and clinical contributors. There is now increasing awareness of the intricate interplay that exists within the historical, financial, cultural, and personal context surrounding these decisions. Previous studies have suggested that non-White patients are both offered and choose surgical treatment for lung cancer less often than White patients, suggesting that further understanding of the context of surgical decision making is imperative.5, 6 Furthermore, surgeon awareness of racial and ethnic disparities might be lower than expected and extend across surgical subspecialties.7, 8 The recent refocus on racial disparities in the USA, in the setting of increasing diversity in the population, is intensifying the urgency of identifying areas of improvement to achieve fairness in surgical care.

Research in context

Evidence before this study

Racial inequities have been described in several surgical fields, with research primarily focusing on surgical morbidity and overall mortality. We searched the MEDLINE, Embase, MedRxiv, and bioRxiv databases from Jan 1, 1995, to April 22, 2021, using the search terms (“Racial disparity” or “Racial inequity”) and (“Surgery”, “Surgical outcomes”, or “Surgical management”). Studies were restricted to those in English or with English translations available. Case reports and meta-analyses were excluded from the search. Previously published relevant studies were reviewed, and 20 additional systematic reviews covering a variety of surgical fields were identified. Research, predominantly in the most recent decade, has revealed inequities in survival outcomes in neurosurgery and other surgical fields, and in the resulting operative and post-operative morbidity in neuro-oncological and other oncological conditions, but scarce data exists assessing the initial access to, and recommendation for, surgery itself.

Added value of this study

This registry-based cohort study improves on previous approaches to identifying surgical inequity in two important ways. First, this study assesses racial disparities in surgery with a primary outcome measure that focuses on the initial management of the patient: the surgeon's recommendation for or against tumour resection. Second, this work accounts for common contributors to racial inequity in health care, including patient-specific, systemic, and provider-specific factors, by using multivariable logistic regression using variables from two large US national databases. These variables include comorbidities, patient race and ethnicity, insurance status, and the rural and urban composition of the region of treatment, in addition to clinical and demographic variables. This provides control for socioeconomic and systemic contributors that were often not accounted for in previous studies.

Implications of all the available evidence

We identified significant racial disparities in surgical recommendations for patients with primary brain tumours, with physicians recommending against surgical resection significantly more often for Black patients than for White patients in the glioblastoma, meningioma, pituitary adenoma, and vestibular schwannoma subgroups. These findings are independent of clinical, demographic, and select socioeconomic and systemic variables. Previous studies have found disparities in morbidity and mortality outcomes in various surgical subspecialties. Taken together, these findings highlight previously unrecognised racial inequities in both management and outcomes of primary brain tumours, indicating a need for increased effort to rectify these health-care disparities.

Data surrounding disparities within neurosurgery are limited to those focusing on the relationship between race, income, and health-care access and how these influence patient outcomes.9, 10 In the most common brain malignancies including glioblastoma, astrocytoma, and oligodendroglioma, initial treatment with surgery is the standard of care and crucial to maximise survival.11, 12, 13, 14, 15 In the most common benign brain tumours, including meningiomas, pituitary adenomas, and vestibular schwannomas, symptoms and growth are the most likely indications for recommending intervention to prevent neurological morbidity.16, 17, 18 Prompt and appropriate surgical management of primary brain tumours is imperative to improve long-term outcomes in these conditions with high potential for morbidity and mortality.

In the most recent decade, research has focused on how disparities influence patient outcomes in neurosurgery. In contrast, little is known about racial and socioeconomic factors that might influence a physician's recommendation for surgery. Given the central role of surgery in the management of neuro-oncological diseases, we sought to understand the relationship between patient-specific factors and a recommendation for surgery. Herein, we investigate racial and socioeconomic disparities in surgery recommendation for primary brain tumours using two large national databases to allow for cross-validation for robustness.

Section snippets

Study design and participants

In this registry-based cohort analysis, we used data from the Surveillance, Epidemiology, and End Results (SEER) database (1975–2016, SEER Registry 18 Custom Data) as well as the American College of Surgeons National Cancer Database (NCDB, 2004–17)19 in the USA for independent analyses. SEER Registry 18 reports cancer incidence and survival data from representative, population-based cancer registries encompassing roughly 28% of the US population. Each registry was selected based on its ability

Results

Patient characteristics from the SEER database are summarised in the appendix (pp 2–5). After data extraction from the SEER database, 63 674 patients with meningioma, 35 258 patients with glioblastoma, 27 506 patients with pituitary adenoma, 11 525 patients with vestibular schwannoma, 5402 patients with astrocytoma, and 3977 patients with oligodendroglioma were included in their respective analyses. Meningiomas had the highest percentage (59·5%) of patients with a recommendation against

Discussion

Recent activity surrounding racial inequality in the USA and persistent racial inequities in resources and outcomes throughout the COVID-19 pandemic have sparked increased focus on disparities within health care. In a national study of both the SEER and NCDB databases, we found that Black patients and patients of unknown race were significantly more likely to receive a recommendation against surgical resection for a number of primary brain tumours compared with White patients, independent of

Data sharing

All input data from the SEER and NCDB databases are available from their source databases. Model data and code are available on request to the corresponding author.

Declaration of interests

We declare no competing interests.

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