ELSEVIER
Available online at www.sciencedirect.com ScienceDirect
journal homepage: www.JournalofSurgicalResearch.com
JSR Surgical Research
Society of Asian Academic Surgeons
Treatment Differences for Adrenocortical Carcinoma by Race and Insurance Status
A ☒ Check for updates
Simon A. Holoubek, DO,a,b,c Erin C. MacKinney, MD,a,d Amna M. Khokar, MD,a,e Kristine M. Kuchta, MS,f David J. Winchester, MD,a,d Richard A. Prinz, MD,a,d and Tricia A. Moo-Young, MDa,d,*
ª NorthShore University HealthSystem, Department of Surgery, Evanston, Illinois
b Augusta University, Otolaryngology Department, Head and Neck Surgery, Augusta, Georgia
“University of Wisconsin School of Medicine and Public Health, Division of Endocrine Surgery, Madison, Wisconsin
d University of Chicago, Department of Surgery, Chicago, Illinois
e Department of Surgery, Stroger Cook County Hospital, Chicago, Illinois f Bioinformatics and Research Core, NorthShore University HealthSystem, Evanston, Illinois
ARTICLE INFO
Article history: Received 3 December 2021 Received in revised form 19 April 2022 Accepted 22 May 2022 Available online 17 August 2022
Keywords:
Adrenal Adrenalectomy Adrenocortical carcinoma Disparity Outcomes
ABSTRACT
Introduction: To determine if treatment and clinical outcomes of adrenocortical carcinoma (ACC) vary by race and insurance status.
Methods: ACC patients from the National Cancer Database (2004-2017) were reviewed. Race was defined as White versus minority (Black and Hispanic). Insurance types were private (PI) versus other (Medicaid/uninsured/unknown). Metastatic ACC (M-ACC) was defined as distant metastases at the time of diagnosis; nonmetastatic ACC (NM-ACC) patient had no distant disease.
Results: Of 2351 NM-ACC patients, 83.6% were White and 16.4% minority. There were 1216 M-ACC patients, with 80.3% White and 19.8% minority. Both White NM-ACC and M-ACC patients had more PI (each P < 0.001). PI NM-ACC was associated with a shorter duration from diagnosis to first treatment (14 versus 18 d, P = 0.005). Both NM-ACC and M-ACC with PI were more likely to receive surgery (92.6% versus 86.9%, P = 0.001 and 35.4% versus 27%, P = 0.02) and to receive surgery sooner (13 versus 16 d, P = 0.03). M-ACC with PI were more likely to receive chemotherapy (63.6% versus 54.3%, P = 0.01) and to have lymph nodes examined (14.8% versus 8.6%, P = 0.02). Length of stay postoperatively was shorter for White NM-ACC (6 versus 7 d, P = 0.04) and M-ACC (8 versus 17 d, P = 0.02). For NM-ACC and M-ACC, the 30-d readmission, 90-d mortality, and overall survival were similar by race. A multivariable analysis showed minorities (OR 0.69, 95% confidence interval 0.54-0.88, P = 0.003) and patients without PI (OR 0.75, 95% confidence interval 0.58-0.97, P = 0.03) were less likely to have surgery. However, a multivariable analysis showed survival was similar for White versus minority patients and PI versus other.
* Corresponding author. NorthShore University HealthSystem, Department of Surgery, 2650 Ridge Avenue, Walgreen Suite 2507, Evan- ston, Illinois 60201. Tel .: +1 1847 570 1700; fax: +1 1847 733 5296. E-mail address: tmoo-young@northshore.org (T.A. Moo-Young). 0022-4804/$ - see front matter @ 2022 Published by Elsevier Inc. https://doi.org/10.1016/j.jss.2022.05.011
Conclusions: White NM-ACC or M-ACC and PI were more likely to receive surgery and timely multimodality care. These disparities were not associated with differences in 90-d mor- tality or overall survival.
@ 2022 Published by Elsevier Inc.
Introduction
Adrenocortical carcinoma (ACC) is a rare disease with an approximately one case per million annual worldwide inci- dence.1,2 It has a 1.5:1 female to male ratio and is associated with a poor prognosis, especially when it is diagnosed at late stages of the disease.3 Surgical resection with negative tumor margins is associated with superior long-term outcomes. However, ACC presents as advanced disease in 50%-70% of patients. Both positive surgical margins and lymph node involvement are associated with poor outcomes.4,5 Patients who present with metastatic disease are at a higher risk for recurrence and are candidates for adjuvant chemotherapy.6
Adrenal surgery has increased over the past 2 decades by almost 50%.7 This increase is multifactorial and is likely due to increased diagnosis from incidental high resolution cross- sectional imaging (computed tomography and magnetic reso- nance imaging) and the widespread adoption of minimally invasive adrenalectomy. The rise of laparoscopic-assisted and robotic-assisted surgical approaches is generally associated with decreased postoperative morbidity.8
Health disparities have been implicated as an important factor with regard to poor healthcare access and worse sur- gical outcomes for several conditions in the United States.9-12 Race and socioeconomic status have been suggested as an important variable when studying outcomes in colorectal cancer, cardiac surgery, and orthopedic surgery. A study by Ahuja et al. found that 30% of African Americans presented with life-threatening symptoms compared to only 26.8% of White patients when being treated for colon cancer.13 This study also revealed that in-hospital mortality was 4.2% for Blacks compared to only 3.7% for Whites.13 A study by Dou- beni et al. in cancer revealed 5-y survival for Black patients with colorectal cancer was decreased at 65% compared to White patients at 70%.14 In cardiac surgery, Black patients had a 1.7% incidence of renal failure requiring hemodialysis compared to 1% in White patients.15 When studying patients with severe aortic stenosis, Yeung et al. noted 53% of White patients received a valve compared to only 39% of Black Americans.16 Singh et al. found higher 30-d readmission rates for Blacks than Whites receiving a knee arthroplasty.17 Similar findings have been reported in breast cancer.18 Black patients were less likely to have a diagnostic evaluation within 30 d of a concerning physical examination or radiologic finding compared to Whites.18
Health disparities studies are relevant in endocrine surgery as well. A national database study with 16,878 patients found that Blacks had a higher overall complication rate at 4.9% compared to 3.8% in Whites after thyroidectomy.19 Adrenal surgery is also associated with disparities including less ac- cess to high-volume surgeons, greater length of hospital stay, and an increase in the complication rate.2º Our objective was
to determine if treatment and clinical outcomes of ACC varied by race and insurance status.
The National Cancer Database (NCDB) is a joint program of the American College of Surgeons and the American Cancer Society that provides standardized information on nearly all types of cancer. There is a specific dataset maintained for ACC. The NCDB includes overall survival (OS) but not disease specific survival. This database is useful for rare diseases such as ACC-provider hospital registry data from more than 1500 Commission on Cancer-accredited facilities. It’s data repre- sent more than 72% of newly diagnosed cancer cases in the United States and more than 40 million historical records.
Methods
The NCDB from 2004 to 2017 was queried for ACC patients using the primary site code C74.X and histology codes 8010, 8140, and 8370. Only patients aged 18 y and older were included. These were divided into nonmetastatic ACC (NM-ACC) and metastatic ACC (M-ACC) groups.
Race was defined as White versus minority (Black and His- panic). Insurance type was defined as private (PI) versus other (Medicaid/uninsured/unknown). Patients with Medicare were excluded in the analyses. Asian, Pacific Islander, and Native American are categorized in the NCDB. However, they were excluded from the final analyses due to a small sample size.
Results were summarized as frequency with percentage, mean with standard deviation, or median with interquartile range (IQR). Comparisons of descriptive statistics between patients were performed using Chi-squared test, Fisher’s exact test, Wilcoxon rank-sum test, and independent t-test as appropriate. The Kaplan-Meier method was used to compute median and 95% confidence interval OS. Multivariable Cox and logistic regression analyses were performed for NM-ACC and M-ACC patients to evaluate factors associated with OS and having their surgery. Covariates included age, gender, race, insurance, income level, Charlson Comorbidity Index, tumor size, facility volume, and metastatic disease. All of the statistical analyses were performed with SAS 9.4 software (SAS Institute, Cary, North Carolina) with a significance level of P < 0.05 and two-sided tests.21
Results
There were 3567 patients with ACC in our overall analysis. Two thousand three hundred and fifty one were NM-ACC, of whom 83.6% were White and 16.4% were minority (Table 1). There were 1216 M-ACC patients, of whom 80.3% were White and 19.8% were minority (Table 2). Both White NM-ACC and M-ACC patients were more likely to have PI (each P < 0.001)
| Table 1 - Characteristics of NM-ACC patients by race. | ||||
|---|---|---|---|---|
| Patient charcteristics | Nonmetastatic | |||
| All | White | Black or Hispanic | P value | |
| N (%) | N (%) | N (%) | ||
| Total patients | 2351 | 1966 | 385 | - |
| Age [mean ± SD] | 57 ± 16 | 57 ± 16 | 53 ± 16 | <0.0001 |
| Gender | 0.0002 | |||
| Male | 952 (40.5) | 829 (42.2) | 123 (31.9) | |
| Female | 1399 (59.5) | 1137 (57.8) | 262 (68.1) | |
| Race | <0.0001 | |||
| White | 1966 (83.6) | 1966 (100) | 0 (0.0) | |
| Black | 228 (9.7) | 0 (0.0) | 228 (59.2) | |
| Hispanic | 157 (6.7) | 0 (0.0) | 157 (40.8) | |
| Insurance | <0.0001 | |||
| Private | 1207 (51.3) | 1026 (52.2) | 181 (47) | |
| Medicare | 784 (33.3) | 692 (35.2) | 92 (23.9) | |
| Medicaid/Other government | 191 (8.1) | 135 (6.9) | 56 (14.5) | |
| Unknown/Uninsured | 169 (7.2) | 113 (5.7) | 56 (14.5) | |
| Income | <0.0001 | |||
| <$38,000 | 342 (14.5) | 241 (12.3) | 101 (26.2) | |
| $38,000-$62,999 | 1077 (45.8) | 907 (46.1) | 170 (44.2) | |
| ≥$63,000 | 716 (30.5) | 633 (32.2) | 83 (21.6) | |
| Unknown | 216 (9.2) | 185 (9.4) | 31 (8.1) | |
| Charlson comorbidity index | 0.6001 | |||
| 0 | 1706 (72.6) | 1434 (72.9) | 272 (70.6) | |
| 1 | 461 (19.6) | 382 (19.4) | 79 (20.5) | |
| ≥2 | 184 (7.8) | 150 (7.6) | 34 (8.8) | |
| Facility type (patients >40 only) | 0.1939 | |||
| Academic/Research | 1040 (52.1) | 871 (51.4) | 169 (56.1) | |
| INCP | 229 (11.5) | 190 (11.2) | 39 (13.0) | |
| CCCP | 615 (30.8) | 536 (31.6) | 79 (26.2) | |
| CCP | 111 (5.6) | 97 (5.7) | 14 (4.7) | |
| Tumor size | 0.4577 | |||
| <5.0 cm | 298 (12.7) | 244 (12.4) | 54 (14.0) | |
| 5.0-9.9 cm | 821 (34.9) | 681 (34.6) | 140 (36.4) | |
| ≥10.0 cm | 1027 (43.7) | 863 (43.9) | 164 (42.6) | |
| Unknown | 205 (8.7) | 178 (9.1) | 27 (7.0) | |
| Days to first treatment [median (Q1-Q3)] | 0 (0-20) | 0 (0-19) | 0 (0-25) | 0.5678 |
| Radiation | 335 (14.2) | 285 (14.5) | 50 (13.0) | 0.4385 |
| Chemotherapy | 641 (27.3) | 550 (28.0) | 91 (23.6) | 0.0804 |
| Radiation and chemotherapy | 168 (7.1) | 143 (7.3) | 25 (6.5) | 0.5868 |
| Radiation or chemotherapy | 808 (34.4) | 692 (35.2) | 116 (30.1) | 0.0555 |
| Lymph nodes examined | 443 (19.9) | 372 (20.0) | 71 (19.3) | 0.7600 |
| Number of nodes examined [median (min-max)] | 0 (0-38) | 0 (0-37) | 0 (0-38) | 0.9444 |
| Surgery | 2020 (85.9) | 1695 (86.2) | 325 (84.4) | 0.3531 |
| Days to definitive surgery [median (Q1-Q3)] | 0 (0-19) | 0 (0-19) | 0 (0-22) | 0.6010 |
| Follow-up, y [median (Q1-Q3)] | 2.3 (0.7-5.2) | 2.4 (0.7-5.3) | 2.2 (0.7-4.9) | 0.4936 |
(92.6% versus 86.9%, P = 0.001 and 35.4% versus 27%, P = 0.02 respectively) (Table 4). NM-ACC patients with PI also had a shorter median IQR interval from diagnosis to surgery ([0-16] versus. [0-20 d, P = 0.03]) (Table 3). M-ACC patients with PI were
| Table 2 - Characteristics of M-ACC patients by race. | ||||
|---|---|---|---|---|
| Patient charcteristics | Metastatic | |||
| All | White | Black or Hispanic | P value | |
| N (%) | N (%) | N (%) | ||
| Total patients | 1216 | 976 | 240 | - |
| Age [mean ± SD] | 56 ± 16 | 57 ± 16 | 53 ± 15 | <0.0001 |
| Gender | 0.5452 | |||
| Male | 511 (42.0) | 406 (41.6) | 105 (43.8) | |
| Female | 705 (58.0) | 570 (58.4) | 135 (56.3) | |
| Race | <0.0001 | |||
| White | 976 (80.3) | 976 (100) | 0 (0.0) | |
| Black | 145 (11.9) | 0 (0.0) | 145 (60.4) | |
| Hispanic | 95 (7.8) | 0 (0.0) | 95 (39.6) | |
| Insurance | <0.0001 | |||
| Private | 568 (46.7) | 476 (48.8) | 92 (38.3) | |
| Medicare | 392 (32.2) | 332 (34.0) | 60 (25.0) | |
| Medicaid/Other government | 125 (10.3) | 80 (8.2) | 45 (18.8) | |
| Unknown/Uninsured | 131 (10.8) | 88 (9.0) | 43 (17.9) | |
| Income | <0.0001 | |||
| <$38,000 | 218 (17.9) | 137 (14.0) | 81 (33.8) | |
| $38,000-$62,999 | 574 (47.2) | 469 (48.1) | 105 (43.8) | |
| ≥$63,000 | 361 (29.7) | 317 (32.5) | 44 (18.3) | |
| Unknown | 63 (5.2) | 53 (5.4) | 10 (4.2) | |
| Charlson comorbidity index | 0.3332 | |||
| 0 | 862 (70.9) | 701 (71.8) | 161 (67.1) | |
| 1 | 238 (19.6) | 186 (19.1) | 52 (21.7) | |
| ≥2 | 116 (9.5) | 89 (9.1) | 27 (11.3) | |
| Facility type (patients ≥ 40 only) | 0.0024 | |||
| Academic/Research | 466 (45.0) | 362 (42.8) | 104 (54.7) | |
| INCP | 112 (10.8) | 87 (10.3) | 25 (13.2) | |
| CCCP | 379 (36.6) | 331 (39.2) | 48 (25.3) | |
| CCP | 78 (7.5) | 65 (7.7) | 13 (6.8) | |
| Tumor size | 0.4862 | |||
| <5.0 cm | 105 (8.6) | 89 (9.1) | 16 (6.7) | |
| 5.0-9.9 cm | 300 (24.7) | 245 (25.1) | 55 (22.9) | |
| ≥10.0 cm | 579 (47.6) | 460 (47.1) | 119 (49.6) | |
| Unknown | 232 (19.1) | 182 (18.6) | 50 (20.8) | |
| Days to first treatment [median (Q1-Q3)] | 19 (6-37) | 19 (6-37) | 25 (8-50) | 0.0041 |
| Radiation | 160 (13.2) | 137 (14.0) | 23 (9.6) | 0.0675 |
| Chemotherapy | 637 (52.4) | 512 (52.5) | 125 (52.1) | 0.9169 |
| Radiation and chemotherapy | 94 (7.7) | 82 (8.4) | 12 (5.0) | 0.0771 |
| Radiation or chemotherapy | 703 (57.8) | 567 (58.1) | 136 (56.7) | 0.6883 |
| Lymph nodes examined | 129 (11.2) | 111 (12.1) | 18 (7.8) | 0.0670 |
| Number of nodes examined [median (min-max)] | 0 (0-50) | 0 (0-50) | 0 (0-45) | 0.2402 |
| Surgery | 359 (29.5) | 301 (30.8) | 58 (24.2) | 0.0423 |
| Days to definitive surgery [median (Q1-Q3)] | 12 (0-38) | 13 (0-38) | 10 (0-36) | 0.7774 |
| Follow-up, y [median (Q1-Q3)] | 0.3 (0.1-1.1) | 0.3 (0.1-1.1) | 0.4 (0.1-1.2) | 0.8570 |
more likely to receive chemotherapy (63.6% versus 54.3%, P = 0.01) and have lymph nodes examined (14.8% versus 8.6%, P = 0.02) than M-ACC patients without private insurance (Table 4).
Median length of stay postoperatively was shorter for White NM-ACC patients (6 versus 7 d, P = 0.04) and M- ACC patients (8 versus 17 d, P = 0.02) (Tables 1 and 2). For NM-ACC and M-ACC patients, the 30-d readmission,
| Table 3 - Characteristics of NM-ACC patients by insurance type. | |||
|---|---|---|---|
| Patient charcteristics | Nonmetastatic | ||
| Other* | Private | P value | |
| N (%) | N (%) | ||
| Total patients | 360 | 1207 | - |
| Age [mean ± SD] | 49 ± 14 | 50 ± 13 | 0.5308 |
| Gender | 0.2046 | ||
| Male | 153 (42.5) | 468 (38.8) | |
| Female | 207 (57.5) | 739 (61.2) | |
| Race | <0.0001 | ||
| White | 248 (68.9) | 1026 (85.0) | |
| Black | 52 (14.4) | 115 (9.5) | |
| Hispanic | 60 (16.7) | 66 (5.5) | |
| Insurance | <0.0001 | ||
| Private | 0 (0.0) | 1207 (100) | |
| Medicare | 0 (0.0) | 0 (0.0) | |
| Medicaid/Other government | 191 (53.1) | 0 (0.0) | |
| Unknown/Uninsured | 169 (46.9) | 0 (0.0) | |
| Income | <0.0001 | ||
| <$38,000 | 86 (23.9) | 139 (11.5) | |
| $38,000-$62,999 | 180 (50.0) | 525 (43.5) | |
| ≥$63,000 | 72 (20.0) | 418 (34.6) | |
| Unknown | 22 (6.1) | 125 (10.4) | |
| Charlson comorbidity index | 0.1706 | ||
| 0 | 276 (76.7) | 951 (78.8) | |
| 1 | 59 (16.4) | 202 (16.7) | |
| ≥2 | 25 (6.9) | 54 (4.5) | |
| Tumor size | <0.0001 | ||
| <5.0 cm | 27 (7.5) | 162 (13.4) | |
| 5.0-9.9 cm | 121 (33.6) | 399 (33.1) | |
| ≥10.0 cm | 160 (44.4) | 573 (47.5) | |
| Unknown | 52 (14.4) | 73 (6.0) | |
| Days to first treatment [median (Q1-Q3)] | 0 (0-25) | 0 (0-17) | 0.0049 |
| Radiation | 50 (13.9) | 188 (15.6) | 0.4338 |
| Chemotherapy | 105 (29.2) | 407 (33.7) | 0.1060 |
| Radiation and chemotherapy | 24 (6.7) | 113 (9.4) | 0.1121 |
| Radiation or chemotherapy | 131 (36.4) | 482 (39.9) | 0.2264 |
| Lymph nodes examined | 76 (22.4) | 247 (21.5) | 0.7366 |
| Number of nodes examined [median (min-max)] | 0 (0-35) | 0 (0-38) | 0.7276 |
| Surgery | 313 (86.9) | 1118 (92.6) | 0.0008 |
| Days to definitive surgery [median (Q1-Q3)] | 0 (0-20) | 0 (0-16) | 0.0312 |
| Follow-up, y [median (Q1-Q3)] | 2.3 (0.6-4.9) | 2.8 (1.0-6.0) | 0.0004 |
90-d mortality, and OS were similar with regard to race (Tables 1 and 2).
There was no difference in OS for all NM-ACC and for surgical NM-ACC patients with regard to race (Fig. 1A and B). There was also no difference for all M-ACC and for M-ACC patients receiving surgery (Fig. 2A and B).
A multivariable analysis showed that minorities (OR 0.69, 95% CI 0.54-0.88, P = 0.003) and patients without PI (OR 0.75, 95% CI 0.58-0.97, P = 0.03) were less likely to have surgery.
However, a multivariable analysis revealed survival was similar for White versus minority patients and those with PI versus other insurance types (Table 5).
Discussion
Health disparities are an important issue for surgical pa- tients in the United States. Poorer overall health and
| Table 4 - Characteristics of M-ACC patients by insurance type. | |||
|---|---|---|---|
| Patient charcteristics | Metastatic | ||
| Other* | Private | P value | |
| N (%) | N (%) | ||
| Total patients | 256 | 568 | - |
| Age [mean ± SD] | 47 ± 14 | 51 ± 13 | 0.0002 |
| Gender | 0.4064 | ||
| Male | 112 (43.8) | 231 (40.7) | |
| Female | 144 (56.3) | 337 (59.3) | |
| Race | <0.0001 | ||
| White | 168 (65.6) | 476 (83.8) | |
| Black | 41 (16.0) | 62 (10.9) | |
| Hispanic | 47 (18.4) | 30 (5.3) | |
| Insurance | <0.0001 | ||
| Private | 0 (0.0) | 568 (100) | |
| Medicare | 0 (0.0) | 0 (0.0) | |
| Medicaid/Other government | 125 (48.8) | 0 (0.0) | |
| Unknown/Uninsured | 131 (51.2) | 0 (0.0) | |
| Income | 0.0126 | ||
| <$38,000 | 57 (22.3) | 99 (17.4) | |
| $38,000-$62,999 | 130 (50.8) | 250 (44.0) | |
| ≥$63,000 | 58 (22.7) | 180 (31.7) | |
| Unknown | 11 (4.3) | 39 (6.9) | |
| Charlson comorbidity index | 0.9551 | ||
| 0 | 194 (75.8) | 430 (75.7) | |
| 1 | 44 (17.2) | 95 (16.7) | |
| ≥2 | 18 (7.0) | 43 (7.6) | |
| Tumor size | 0.0120 | ||
| <5.0 cm | 16 (6.3) | 44 (7.7) | |
| 5.0-9.9 cm | 54 (21.1) | 123 (21.7) | |
| ≥10.0 cm | 120 (46.9) | 309 (54.4) | |
| Unknown | 66 (25.8) | 92 (16.2) | |
| Days to first treatment [median (Q1-Q3)] | 21 (7-38) | 18 (6-37) | 0.2005 |
| Radiation | 29 (11.3) | 78 (13.7) | 0.3420 |
| Chemotherapy | 139 (54.3) | 361 (63.6) | 0.0118 |
| Radiation and chemotherapy | 20 (7.8) | 50 (8.8) | 0.6370 |
| Radiation or chemotherapy | 148 (57.8) | 389 (68.5) | 0.0029 |
| Lymph nodes examined | 20 (8.6) | 80 (14.8) | 0.0184 |
| Number of nodes examined [median (min-max)] | 0 (0-50) | 0 (0-23) | 0.0653 |
| Surgery | 69 (27.0) | 201 (35.4) | 0.0170 |
| Days to definitive surgery [median (Q1-Q3)] | 12 (0-40) | 10 (0-34) | 0.2539 |
| Follow-up, y [median (Q1-Q3)] | 0.4 (0.1-1.2) | 0. (0.2-1.4) | 0.1461 |
decreased life span based on race or ethnicity are multi- factorial.22,23 Minority status and insurance may predispose patients to lower quality or reduced access to healthcare, including restrictions to providers who do not accept Medicaid.24,25 Studying these factors associated with health disparities may lead to improved outcomes in the future by identifying differences in care provided to people who have the same disease.
While this study revealed significant differences in care, OS was similar. This suggests that the altered care patterns did not translate to differences associated with decreased sur- vival. Hammad et al. at the Medical College of Wisconsin also found that while ACC care varied by race, this was not inde- pendently associated with decreased survival in ACC.26 Age >55 y and comorbidities were associated with decrease sur- vival, while race was not.26
A
Product-Limit Survival Estimates With Number of Subjects at Risk
1.0
0.8
Survival Probability
0.6
0.4
0.2
0.0
1
385
207
124
71
41
22
2
1966
1080
669
421
254
142
0
2
4
6
8
10
Years
Race
1: Black or Hispanic
2: White
B
Product-Limit Survival Estimates With Number of Subjects at Risk
1.0
0.8
Survival Probability
0.6
0.4
0.2
0.0
1
325
192
114
64
36
19
2
1695
1024
644
407
246
138
0
2
4
6
8
10
Years
Race
1: Black or Hispanic
2: White
Disparities in healthcare have multiple causes including socioeconomic standing, insurance status, access to care, health literacy, language, and cultural differences. Length- of-stay differences by race despite no difference in tumor
size or comorbidities may suggest the higher income in White patients that may play a role in discharge after sur- gery. Even when these differences do not translate into sig- nificant decreases in OS, further study is needed to better
A
Product-Limit Survival Estimates With Number of Subjects at Risk
1.0
0.8
Survival Probability
0.6
0.4
0.2
0.0
1
240
37
12
2
1
0
2
976
133
56
27
15
7
0
2
4
6
8
10
Years
Race
1: Black or Hispanic
2: White
B
Product-Limit Survival Estimates With Number of Subjects at Risk
1.0
0.8
Survival Probability
0.6
0.4
0.2
0.0
1
58
18
4
0
2
301
81
35
16
7
3
0
2
4
6
8
10
Years
Race
1: Black or Hispanic
2: White
understand trends in healthcare including diagnosis, time to first treatment being offered, use of surgery, and multimodal care.
While our study revealed that having PI was an important factor with regard to care offered to patients, the inability to detect a difference in OS may relate to ACC. This disease is
| Table 5 - Multivariable survival and logistic regression analysis. | ||||
|---|---|---|---|---|
| Patient charcteristics | Survival | Surgery | ||
| HR (95% CI) | P value | OR (95% CI) | P value | |
| Age | ||||
| 40-54 versus 18-39 | 1.34 (1.20-1.50) | <0.0001 | 0.70 (0.55-0.90) | 0.0047 |
| 55-69 versus 18-39 | 1.86 (1.60-2.16) | <0.0001 | 0.31 (0.22-0.43) | <0.0001 |
| ≥70 versus 18-39 | 0.95 (0.82-1.09) | 0.4520 | 1.19 (0.87-1.63) | 0.2759 |
| Gender, male versus female | 1.10 (1.01-1.19) | 0.0365 | 0.81 (0.67-0.97) | 0.0257 |
| Race, Black, or Hispanic versus White | 0.98 (0.88-1.10) | 0.7883 | 0.69 (0.54-0.88) | 0.0029 |
| Insurance | ||||
| Other versus Private | 1.11 (0.98-1.25) | 0.1082 | 0.75 (0.58-0.97) | 0.0302 |
| Medicare versus Private | 1.20 (1.07-1.36) | 0.0030 | 0.74 (0.57-0.96) | 0.0236 |
| Income | ||||
| $38,000-$62,999 versus < $38,000 | 0.98 (0.87-1.11) | 0.7431 | 1.22 (0.94-1.59) | 0.1300 |
| ≥$63,000 versus < $38,000 | 0.91 (0.80-1.04) | 0.1824 | 1.04 (0.78-1.37) | 0.8092 |
| Unknown versus < $38,000 | 0.49 (0.39-0.62) | <0.0001 | 1.97 (1.27-3.05) | 0.0026 |
| Charlson comorbidity index | ||||
| 1 versus 0 | 1.33 (1.19-1.47) | <0.0001 | 0.85 (0.67-1.07) | 0.1655 |
| ≥2 versus 0 | 1.60 (1.38-1.85) | <0.0001 | 0.71 (0.52-0.97) | 0.0335 |
| Tumor size | ||||
| 5.0-9.9 versus < 5.0 cm | 1.25 (1.07-1.45) | 0.0053 | 1.02 (0.74-1.40) | 0.9061 |
| ≥10.0 versus < 5.0 cm | 1.30 (1.12-1.50) | 0.0006 | 1.41 (1.03-1.93) | 0.0298 |
| Unknown versus < 5.0 cm | 1.71 (1.43-2.03) | <0.0001 | 0.22 (0.15-0.32) | <0.0001 |
| Facility volume, high versus Low | 0.84 (0.76-0.92) | 0.0003 | 2.09 (1.68-2.61) | <0.0001 |
| Metastatic disease, yes versus no | 3.81 (3.48-4.17) | <0.0001 | 0.05 (0.04-0.06) | <0.0001 |
rare and associated with poor prognosis. Therefore, it may be difficult to detect a survival difference even when care is different because its prognosis is so poor and few institutions see this disease with any frequency.
Limitations of our study include its retrospective design, relatively short follow-up, missing database values, coding errors, or changes in coding practices during course of this study. In addition, rates for surgical management for patients with metastatic ACC may be inflated. Surgical site codes in the NCDB are not specific to ACC. Cases with local tumor excision and surgery, not otherwise specified were included. About 90% of metastatic ACC patients with surgery had codes for simple, total, or radical surgery. However, this limitation of the database could not be directly controlled and may lead to data suggestion overtreatment of metastatic ACC.
Conclusions
There are differences in care based on race and insurance status. Patients with private insurance and White race with NM-ACC or M-ACC were both more likely to receive surgery and timely multimodality care. However, these disparities were not associated with differences in 90-d mortality or OS.
Author Contributions
All authors contributed significantly to this manuscript. A.H., E.M., A.K., A.W., R.P., and T.M.Y. contributed to study design.
S.H. and K.K. contributed to data analysis. S.H., E.M., R.P., and T.M.Y. contributed to editing and final review.
Disclosure
None declared.
Funding
None.
Meeting Presentation
Society of Asian Academic Surgeons; Chicago, IL; September 25-27, 2021.
REFERENCES
1. Kerkhofs T, Verhoeven R, Van der Zwan J, et al. Adrenocortico carcinoma: a population-based study on incidence and survival in The Netherlands since 1993. Eur K Cancer. 2013;49:2579-2586.
2. Kebebew E, Reiff E, Duh Q, Clark O, McMillan A. Extent of disease at presentation and outcome for adrenocortical carcinoma have we made progress? World J Surg. 2006;30:872-878.
3. Allolio B, Fassnacht M. Clinical review: adrenocortical carcinoma: clinical update. J Clin Endocrinol Metab. 2006;91:2027-2037.
4. Margonis G, Kim Y, Prescott J, et al. Adrenocortical carcinoma: impact of surgical margin statos on long-term outcomes. Ann Surg Oncol. 2016;23:134-141.
5. Paton B, Novitsky Y, Zerey M, et al. Outcomes of adrenal cortical carcinoma in the United States. Surgery. 2006;140:914-920.
6. Terzolo M, Angeli A, Fassnacht M, et al. Adjuvant mitotane treatment for adrenocortical carcinoma. N Engl J Med. 2007;356:2372-2380.
7. Sauders B, Wainess R, Dimick J, Upchurch G, Doherty G, Gauger P. Trends in utilization of adrenalectomy in the United States: have indications changed? World J Surg. 2004;28:1169-1175.
8. Carr A, Wang T. Minimally invasive adrenalectomy. Surg Oncol Clin N Am. 2016;25:139-152.
9. Daraei P, Moore CE. Racial disparity among the head and neck cancer population. J Cancer Educ. 2015;30:546-551.
10. Jaruvongvanich V, Assavapongpaiboon B, Wong L. Racial/ ethnic disparities in gallbladder cancer receipt of treatments. J Gastrointest Oncol. 2018;9:348-353.
11. Harari A, Li N, Yeh MW. Racial and socioeconomic disparities in presentation and outcomes of well-differentiated thyroid cancer. J Clin Endocrinol Metab. 2014;99:133-141.
12. Noureldine SI, Abbas A, Tufano RP, et al. The impact of surgical volume on racial disparity in thyroid and parathyroid surgery. Ann Surg Oncol. 2014;21:2733-2739.
13. Ahuja N, Chang D, Gearhart SL. Disparities in colon cancer presentation and in-hospital mortality in Maryland: a ten- year review. Ann Surg Oncol. 2007;14:411-416.
14. Doubeni CA, Field TS, Buist DS, et al. Racial differences in tumor stage and survival for colorectal cancer in an insured population. Cancer. 2007;109:612-620.
15. Hravnak M, Ibrahim S, Kaufer A, Sonel A, Conigliaro J. Racial disparities in outcomes following coronary artery bypass grafting. J Cardiovasc Nurs. 2006;21:367-378.
16. Yeung M, Kerrigan J, Sodhi S, et al. Racial differences in rates of aortic valve replacement in patients with severe aortic stenosis. Am J Cardiol. 2013;112:991-995.
17. Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data. Ann Rheum Dis. 2014;73:2107-2115.
18. Tammemagi CM. Racial/ethnic disparities in breast and gynecologic cancer treatment and outcomes. Curr Opin Obstet Gynecol. 2007;19:31-36.
19. Sosa JA, Mehta PJ, Wang TS, Yeo HL, Roman SA. Racial disparities in clinical and economic outcomes from thyroidectomy. Ann Surg. 2007;246:1083-1091.
20. Holoubek SA, Maxwell J, Fingeret AL. Racial disparities of adrenalectomy. J Endocr Soc. 2020;4. https://doi.org/10.1210/ jendso/bvaa110. bvaa110.
21. Statistical analysis system version 9.3 SAS Institute Inc., Cary, NC.
22. Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA. 1998;279: 1703-1708.
23. Sorlie PD, Backlund E, Keller JB. US mortality by economic, demographic, and social characteristics: the National Longitudinal Mortality Study. Am J Public Health. 1995;85:949-956.
24. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283:2579-2584.
25. Andrulis DP. Access to care is the centerpiece in the elimination of socioeconomic disparities in health. Ann Intern Med. 1998;129:412-416.
26. Hammad AY, Yen TWF, Carr AA, Evans DB, Wang TS. Disparities in access to care and outcomes in patients with adrenocortical carcinoma. J Surg Res. 2017;213:138-146. https://doi.org/10.1016/j.jss.2017.02.046. Epub 2017 Mar 3. PMID: 28601306.