Impact Of Socioeconomic Status On Brain Metastasis Outcomes At A Large Academic Radiosurgery Center

To examine potential socioeconomic disparities in brain metastasis treatment outcomes, we assessed the role of race/ethnicity, insurance coverage, and socioeconomic status on outcomes for patients treated with stereotactic radiosurgery for brain metastasis at a tertiary referral center. Between 7/2000 and 1/2013, a retrospective review was performed on a total of 737 patients with brain metastasis who were treated with stereotactic radiosurgery at a single institution. Patients were stratified by estimated median income (based on zip-code data), race/ethnicity, and insurance status (uninsured vs. Medicare vs. Medicaid vs. private) as well as oncologic characteristics. Clinical outcomes assessed were overall survival, local failure, distant brain failure, and neurologic death. RTOG symptom grade at time of presentation was also assessed. Kaplan-Meier analysis was used to estimate survival times and Cox proportion hazard regression was used for multivariate analysis. A lower estimated median income predicted for a higher RTOG symptom grade at time of diagnosis with brain metastasis (Pearson correlation coefficient -0.12, p=0.0008). Neither race/ethnicity (p=0.6) nor insurance status (p=0.7) had a significant association with symptom grade at time of diagnosis. However, lower income was not associated with worsening overall survival (HR = 0.99), local control (HR = 0.99), distant brain failure (HR = 0.98) or increased likelihood of neurologic death (HR = 0.99). Neither lack of insurance (HR = 1.07) nor race/ethnicity were associated with worsening overall survival. Lack of insurance (HR = 0.92) was not associated with local control, though Hispanic ethnicity had a non-significant association with worsened local control (HR = 2.0, p= 0.15). Distant brain failure was increased in Hispanic patients (HR = 2.79, p= 0.04) as compared to Caucasians. Lack of insurance was not associated with distant brain failure (HR = 1.33). Neither lack of insurance (HR = 1.03) nor race/ethnicity (HR = 1.0) affected the likelihood of neurologic death. Patients with lower estimated income had higher RTOG grade neurologic symptoms at presentation with brain metastasis. However, clinical outcomes were not significantly different once these patients were managed at a large academic medical center. Further studies are necessary to assess the role of access to care and other socioeconomic factors for patients with brain metastasis treated with stereotactic radiosurgery.