There are known racial disparities affecting OS in patients with meningiomas and it has been presumed these are likely due to differences in SES. However, differences remain in outcome in racial and ethnic groups of similar SES, suggesting that other underlying factors may also contribute. To our knowledge, this is the first study to demonstrate differences in tumor and patient characteristics associated with OS within each racial and ethnic group beyond SES. Overall, we found that combinations of tumor characteristics and SES influence OS in a race-specific manner (Fig. 6). White, Hispanic Black, and Black patients were likely to have both aggressive tumor features and low SES that influence OS. Hispanic White patients were mostly influenced by low SES and were less likely to have aggressive tumor features, whereas Asian patients had aggressive tumor features and higher SES (Fig. 6).
We found Black patients are seemingly the most vulnerable population of patients, with a more aggressive tumors and lower SES. Black patients are more likely to have higher grade meningiomas and to undergo STR, both of which are known contributors to worse OS, which is also reflected in our results. 9,10Additionally, they are more likely to lack health insurance and live in areas with a lower median income and education level. Although limited access to hospital facilities has been previously reported for Black patients,4,11,12 our study demonstrates that the Black population can access academic facilities similar to other groups. While SES-related factors can undeniably contribute to poor outcomes, the finding of a higher prevalence of high-grade tumors and higher occurrence of STR among Black patients with meningioma is alarming This finding can potentially help raise awareness for opportunities to improve care for this patient population.
The Hispanic population is unique in that it represents a heterogenous group of individuals with admixture of genetic ancestry.13 Hispanic ethnicity is independent of race and encompasses a population who may also identify and self-report with different races, such as White, Black, or Asian. The heterogeneity of this population can likely account for some of the conflicting results thus far in the literature demonstrating either no difference or improved OS for Hispanic patients with meningiomas.7,14–16 We subclassified Hispanic ethnicity into Hispanic White and Hispanic Black to account for this admixture and its potential influence on outcome. Hispanic White populations have significantly improved OS compared to White populations. Interestingly, the improved OS in the Hispanic White population was seemingly independent of socioeconomic factors that could contribute to worsened OS. Indeed, they tended to have a younger age of presentation, lower grade tumors, and be of female sex. This is consistent with the “Hispanic Paradox” that has been well established in the medical literature, even beyond that of brain tumors (citations). Unfortunately, Black and Hispanic patients have also been reported to receive substandard care with less extensive resections,17–20 which is reflected in our results as well. Similar to Black patients, we found an increased likelihood of higher-grade tumors among the Hispanic Black population that may contribute to worse OS. These findings underscore the need for more specific distinctions in future studies investigating race, ethnicity and outcome, as Hispanic patients in particular cannot simply be grouped together in the same category without significant limitations.
Interestingly, our findings centered around the Asian population may perhaps exemplify the potential positive influence of SES on outcome for patients with meningioma. Indeed we found improved OS for Asians with meningiomas, consistent with prior studies that have shown either no difference or improved OS compared to White patients.7,11,21,22 While we found Asian patients were more likely to have higher grade and larger meningiomas, Asian patients was more likely to have private health insurance and less likely to live in impoverished areas. Asian patients were also the least likely to undergo STR, and thus perhaps the SES and SDOH factors may have helped contribute to an improved OS.
Our findings demonstrate a clear racial disparity in meningioma aggressiveness amongst certain racial/ethnic populations and potential OS implications to form the basis for further investigations with genetic ancestry. To date, there have been no studies focused on elucidating the association between potential underlying genetic and epigenetic factors and tumor biology and behavior. However, these relationships have been well-studied in other tumors. Race-specific driver mutations have been identified in lung, breast, prostate, and colorectal cancer (PMID 34994651). 23 Glial tumors in the Hispanic White and non-Hispanic White patients were more likely to have EGFR expression, whereas Asian-American patients were more likely to have a p53-pathway mutations and these differences can have significant implications in outcome and patient-centered interventions.24 Further studies are necessary to determine the underlying genomic influences that may be associated in the differences we observed in this study.
LIMITATIONS
Our results warrant careful interpretation in the context of the study limitations. The NCDB is a national database, and with potential for selection bias related to non-randomized participation of certain institutions over others. Additionally, there is a certain crudeness in the reported variables in NCDB. Most relevant, our primary outcome, OS, is an “all-cause mortality” and does not distinguish non-meningioma related death to meningioma-related death. This is further compromised by the fact that NCDB does not offer recurrence data which could have been useful in interpreting outcome. The known differences in the average life-expectancy between racial and ethnic groups, such that Asians have the highest life expectancy, followed by Hispanic, White, and Black populations,25 could not be accounted for in our study. Additionally, several SES factors, such as median income and high school diploma percentages, were inferred from zip code.