Impact of socioeconomic status on extent of disease at diagnosis and cancer and ocular outcomes in retinoblastoma: A population-based analysis
Reporter: Jacob Shabason, MD
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: June 6, 2013
Presenter: Bao Truong, BS Presenter's Affiliation: Dana-Farber Cancer Institute, Boston, MA Abstract #: 10011
Retinoblastoma is the most common intraocular cancer of childhood, and accounts for 3% of all pediatric malignancies.
The most common presenting sign of retinoblastoma is leukocoria, which can be easily detected with the examination for a red reflex.
Therefore, primary care physicians play a vital role in the diagnosis of retinoblastoma through performance of routine screening evaluating for a red reflex.
There is a strong correlation between early diagnosis and improved clinical outcome in retinoblastoma.
If the tumor is identified when small and has not yet extended outside of the retina, patients can be treated with globe preservation therapy.
Tumors identified later with vitreous or sub-retinal seeding, however, typically require enucleation.
Although appropriate local therapy generally results in long-term survival, delayed diagnosis tends to lead to more extensive disease and less of a chance for eye preservation or cure.
Barriers to proper primary care screening may delay the diagnosis of retinoblastoma and affect prognosis.
In this SEER registry study the authors analyze the impact of socioeconomic status and ethnicity on the extent of disease, as well as cancer and ocular outcomes.
Materials and Methods
Eighteen SEER registries from 2000-2009 were searched and all retinoblastoma cases (0-9 years) were included in the analysis.
Diagnosis, staging, treatment, gender, race, ethnicity and county of residence were collected on each patient.
The county-based disparity variables analyzed included poverty level, education attainment, language isolation, crowding, and percentage of immigrants.
The cut-off values were defined as the median values for the cohort of patients.
Relative survival was calculated using Ederer II method and estimates were compared using Z-score.
755 case of retinoblastoma were identified and included in this study.
The percentage of patients with extraocular disease was consistently higher in US counties with lower socioeconomic indications, including:
Higher vs. lower poverty status (29.3% vs. 22.1%, p=0.028)
Lower vs. higher education attainment (30.6% vs. 22.7%, p=0.003)
Higher vs. lower crowding (33.2% vs. 18.1%, p<0.001)
Higher vs. lower language isolation (32.2% vs. 19.3%, p<0.001).
Higher vs. lower percentage of immigrants (30.1% vs. 21.4%, p=0.008).
In terms of racial associations, Hispanic patients had significantly higher percentage of extraocular disease compared to other races (35.2% vs. 20.9%, p<0.001).
Worse ocular outcomes, as measured by a higher percentage of enucleation, were associated with counties with low education attainment (75.4% vs. 67.4%, p=0.025), and with Hispanic origin (77% vs. 68.6%, p=0.019).
Decreased survival was associated only with the variable of language isolation (p=0.016), but not with Hispanic origin or other socioeconomic indicators.
There are significant disparities in the care and outcomes of pediatric patients with retinoblastoma.
Lower socioeconomic factors are associated with more extensive disease, presumably from decreased access to primary care physicians and therefore delayed diagnosis.
Hispanic patients in particular tend to have more advanced disease and higher enucleation rates.
The only factor associated with impaired survival is language isolation.
Early diagnosis of retinoblastoma by primary care physicians is vital for improved clinical outcomes and may permit opportunities for early interventions that can avoid the morbid procedure of enucleation.
Socioeconomic and ethnic barriers to care place patients who live in certain underserved communities at higher risk for presenting with later stage disease.
This study indicates a need for improved screening for retinoblastoma in underserved populations and further work is necessary to try to improve this access to care.
When examining the risk factor of race it is sometimes difficult to separate associations due to socioeconomic factors or genetic causes.
The association of more extensive disease in Hispanic populations warrants further investigation into possible genetic causes that may predispose patients to more aggressive disease.
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