March 01, 2022
Due to advances in surgical techniques and medical management for extremity bone sarcomas, limb salvage surgery has become the preferred treatment option for patients with these tumors. While amputation is still sometimes necessary due to tumor characteristics, a 2021 study published in Surgical Oncology found that socioeconomic factors are associated with amputation for extremity bone sarcomas as well.
According to Matthew T. Houdek, M.D., an orthopedic oncologist at Mayo Clinic in Rochester, Minnesota, previous research has suggested insurance status to be a key element leading to amputation.
As Dr. Houdek explains, patients who are uninsured or publicly insured by Medicaid often have similar experiences in terms of delays in care because Medicaid serves as a safety net for patients to enroll at the time of diagnosis — and typically not before. Previous studies analyzed insurance status at the time of diagnosis.
"There was the thought that the main driver of why people had an amputation was because they presented late," said Dr. Houdek. "Theoretically, because they didn't have insurance to initially have something looked at, the tumor grew to the point where we couldn't perform a limb salvage surgery."
Disparities in sarcoma care regardless of insurance
Dr. Houdek and his colleagues considered only patients who had private health insurance for at least one year prior to the sarcoma diagnosis. The researchers reviewed data from the OptumLabs Data Warehouse, a de-identified administrative claims database, for patients who underwent surgical resection of a bone sarcoma between 2006 and 2017. Variables of interest included age, gender, race, income, residence region and type of treatment facility.
"In this study, we wanted to know whether there are still socioeconomic factors that impact either limb salvage or amputation in patients who have health insurance," said Dr. Houdek. "In this insured population, we are still noting the same sort of issue."
Over the course of the study, 1,390 adult patients underwent surgical resection of bone sarcoma. Of those, 1,138 were treated with limb salvage and 252 were treated with amputation. All patients' bone sarcomas were located in an upper or lower extremity.
Risk factors for amputation included:
- Annual household income lower than $75,000 a year
- Treatment in public hospitals or hospitals with fewer than 200 beds
- Diagnosis of lower extremity sarcoma
Patients with household incomes greater than $125,000 and those with upper extremity sarcomas had limb salvage surgery. This research illustrates how socioeconomic factors impact sarcoma care regardless of insurance status, which is especially pertinent because 92% of Americans had health insurance coverage in 2019.
In addition to identifying health insurance and socioeconomic factors, researchers also noticed trends in outcomes by race. Compared with those reporting African American race, patients reporting white race trended toward shorter times to the initiation of treatment and improvements in survival as well as higher likelihood to undergo limb salvage surgery. While more research is needed in this area, a potential disparity does exist.
Addressing disparities in sarcoma care
With this data and other emerging research around disparities in cancer care, clinicians can focus on connecting patients with the resources they need when diagnosed with bone sarcoma. This study noted that at least a quarter of the cases reviewed were treated at smaller hospitals (less than 200 beds). Having a surgery performed at a small hospital was associated with higher risk of amputation, whereas having surgery performed at an academic institution was associated with higher rates of limb salvage surgery.
It is imperative that clinicians know what specialty sarcoma services are available in their regions and understand how to connect a patient with those resources. The Mayo Clinic study provides data to support centralization of care for patients with bone sarcoma in the U.S.
Broadly, this study helps further health equity in cancer care by directly identifying disparities that exist for patients with sarcoma. As Dr. Houdek points out, researchers must identify the problem in order to craft solutions that position patients for success. This study illustrates Mayo Clinic's broader commitment to equitable health care for all.
Further research is needed in this area, as it remains unclear exactly why these socioeconomic factors cause delays in care, what role race and ethnicity have in sarcoma care disparities, and how to minimize these inequities to improve the quality of care for patients with bone sarcoma.
For more information
Houdek MT, et al. Socioeconomic factors associated with limb salvage versus amputation for adult extremity bone sarcomas in patients with insurance coverage. Surgical Oncology. 2021;39:101664.
Refer a patient to Mayo Clinic.