Social Determinants of Health in Patients With Mesothelioma

Mesothelioma: MesotheliomaOur earliest written records on mesothelioma date back to the late 18th century, when France's Joseph Lieutaud discovered a tumor in the pleural mesothelium, the lining of the lungs. In 1935, this rare cancer type was first linked to occupational asbestos exposure by British pathologist Steven R. Gloyne. By the end of the 1970s, mesothelioma lawsuits were commonplace, and the global workforce, who had developed cancer due to prolonged exposure to this heat-resistant insulation, demanded restitution and compensation. As of 2018, mesothelioma accounts for less than 0.17 percent of all U.S. cancer diagnoses and is expected to continue decreasing due to our increased understanding of the cause of this tumor type. Yet, in spite of this understanding and the advanced, multimodal treatment options of surgery, chemotherapy, and radiation therapy, patients living with localized malignant pleural mesothelioma (MPM) continue to face poor outcomes related to overall survival (OS). In an observational, retrospective cohort study published in March 2023, researchers at the University of Miami's Leonard M. Miller School of Medicine and the Sylvester Comprehensive Cancer Center investigated whether certain social determinants of health (SDOH) can affect the OS for patients living with operable MPM. “With mesothelioma, mortality rates are typically high,” said Ahmed Alnajar, MD, Quality Management Analyst in the Division of Cardiothoracic Surgery. “Consequently, we aimed to explore risk factors that affect survival for patients with established disease to offer hope through existing treatment options.” Utilizing the National Cancer Database (NCDB), investigators identified 1,389 patients diagnosed with MPM between January 1, 2004, and December 31, 2017. To be included in the study population, patients must have had potentially resectable MPM, been diagnosed with clinical Stage I to Stage IIIA disease, subtyped as having epithelioid or biphasic mesothelioma, and given chemotherapy with or without surgical treatment—either pleurectomy and decortication or extrapleural pneumonectomy. Data on overall survival outcomes for the study population was also collected using NCDB. In this study, OS was defined as the period between diagnosis and the date of last contact or death, whether death was cancer-related or not. “After we identified all patients eligible for surgical treatment—whether they had surgery or not—we compared the length of survival time between patients based on certain characteristics, such as surgical and non-surgical treatment, and increased social determinants of health burden versus other factors,” Alnajar explained. “Then, we adjusted the projected survival estimates based on multiple factors related to patient and tumor characteristics to find a meaningful difference between the analyzed factors and unbiased survival estimates in MPM patients.” Study Details The social determinants of health investigated in this study were zip code-level median income, metropolitan statistical area, educational attainment, and distance between the patient's residence and the hospital that reported the case. Other demographic and hospital-related variables used to adjust survival estimates included age, sex, race and/or ethnicity, and insurance. Using survival statistics in their analysis, researchers were able to determine the differences in OS for the group who had received surgical treatment in comparison to the group who had not. They found that, at 6 months, OS was 92 percent for surgically treated patients compared to 88 percent for non-surgically treated patients. This trend was consistent throughout their analysis when they adjusted to test for OS at 1 year, 3 years, and 5 years. They found that the median OS for patients treated with chemotherapy and surgery was 2.2 years compared to 1.3 years for patients treated with only chemotherapy. After calculating OS for each group, the team included social determinants of health and demographic variables in their analysis and observed how these factors affected OS. They found that the risk factors most associated with poor OS outcomes were Black race and male sex. However, factors such as increased travel distance between a patient's home and their treatment center, especially when treated in academic settings, were associated with improved OS. To demonstrate this statistically, the median OS time for patients who were treated with surgery more than 250 miles from their home was 3.9 years compared to 2.1 years for patients who had received surgery less than 250 miles away. “All health care facilities, including academic, hybrid, and community-facing, should work to make treatments more accessible,” said Samuel Kareff, MD, MPH, a Chief Fellow of Hematology/Oncology training program at the University of Miami Sylvester Comprehensive Cancer Center. “Given our findings that surgical therapy at highly specialized centers may be located far from patients' homes, some options include partnering with patient advocacy groups like Mesothelioma Miracle to offer transportation. Other advocacy groups, including Cancer Alliance and Mesothelioma.net, help patients with this rare diagnosis navigate available treatments and support services.” Statistically insignificant factors included income, educational attainment, and hospital volume. “By generating survival estimates and calculating probability difference, we can tell if the probability of survival obtained from the observed results is unlikely due to random chance, but rather a strong possibility that some patients have better survival than others when grouped by a specific risk factor,” Alnajar explained. Interestingly, Hispanic patients, despite typically low socioeconomic status and access to insurance, were 13 percent more likely to survive than other minority groups, and their mortality rate was not different from their non-Hispanic White counterparts. This may be attributed to the Hispanic paradox, which has been described in other epidemiologic studies showing a higher life expectancy, even though they are met with similar hardships faced by other marginalized racial and ethnic groups. Reasons for this may be explained by a younger population or immigration patterns, but future studies are needed in a larger population with a research question specified to explore this paradox. Drs. Alnajar and Kareff expressed that their ultimate hope for this study is to improve survival outcomes for patients worldwide and, particularly, cure this disease in socioeconomically disadvantaged populations as this disease gets eradicated. “We encourage the public to become familiar with definitive risk factors for mesothelioma, such as asbestos exposure,” Kareff said. “There are currently only 67 countries worldwide that have banned the use of asbestos—and the U.S. is not one of them. Take a moment to write to your legislators.” In 2023, asbestos use in the U.S. is restricted and no longer mined, but it is not fully banned. Unlike the U.K., Canada, Australia, and the European Union, it is still legal to import asbestos and use it in small amounts and in certain products. It can be found in construction materials, such as electrical wiring, tiles, cement, plaster, caulk, and roofing materials. It is also found in vehicle components, like the brake and transmission systems, and in certain fabrics and papers. “The incident cases and deaths are still increasing in resource-limited regions with low socioeconomic index and less asbestos control regulation,” said Estelamari Rodriguez, MD, MPH, co-lead of the Thoracic Site Disease Group and Associate Director for Community Outreach at the University of Miami Sylvester Comprehensive Cancer Center. “Our study highlights disparities in the access to multidisciplinary treatment, which also impacts survival despite asbestos control regulation.” Elizabeth Rose Galamba is a contributing writer.

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