R. Lor Randall, MD, FACS

Proxied poverty exposure, race, and ethnicity were not associated with overall survival (OS) or event-free survival (EFS) disparities among non-Hispanic Black children with nonmetastatic osteosarcoma who received frontline treatment in a clinical trial; however, the risk of death following disease relapse was significantly higher among non-Hispanic Black vs White children, indicating inequities in post-relapse care, according to data published in the Journal of the National Cancer Institute.¹

Investigators conducted a retrospective cohort study of patients with nonmetastatic osteosarcoma between the ages of 5 and 21 years (n = 758) who were enrolled onto the phase 1 AOST0331/ EURAMOS-1 trial (NCT00134030). Results showed 4-year post-relapse survival rates of 35.7% in Hispanic patients, 13.0% in non-Hispanic Black patients, 43.8% in other non-Hispanic patients, and 38.9% non-Hispanic White patients (P = .0046). Additionally, 25.6% and 28.5% of the overall population were household- or neighborhood-poverty exposed, respectively.

“Access [to treatment] for patients with non-metastatic osteosarcoma is good across socioeconomic determinants of health, but for patients that relapse, the [data are] not so optimistic,” R. Lor Randall, MD, FACS, emphasized. “We need to do better for patients that are struggling with relapsed osteosarcoma.”

In an interview, Randall sat down with OncLive^® and discussed key findings from a Children’s Oncology Group (COG) report on the relationship between poverty, race, ethnicity, and survival outcomes in pediatric nonmetastatic osteosarcoma. He also emphasized the importance of ensuring that all patients with cancer, no matter their race or socioeconomic background, are provided with the best available treatment.

Randall serves as the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor at the University of California Davis Comprehensive Cancer Center in Sacramento, California.

OncLive: What was the rationale for evaluating the link between these social determinants of health and survival in pediatric patients with nonmetastatic osteosarcoma?

Randall: There was recently a study performed by the COG looking specifically at poverty, race, ethnicity, and survival in pediatric non-metastatic osteosarcoma based on 1 of their clinical trials. We know that children living in poverty and those of marginalized race or ethnicity experience inferior outcomes across a variety of cancers. [However], we don't know about osteosarcoma, as it's poorly defined.

What methods were utilized throughout your analysis, and what findings did they reveal?

This study looked at the differences in race, ethnicity, and we proxied poverty exposure to look at EFS for children with non-metastatic osteosarcoma. We had 758 patients; [25.6%] were defined as having household poverty, and 28.5% were exposed to neighborhood poverty. This was interesting [based upon the results] that we found.

We proxied the socioeconomic determinants of health for household poverty exposure. This was done by using insurance at time of trial enrollment and was dichotomized as sole coverage by public insurance, such as Medicaid or the Children's Health Insurance Program, vs a private commercial payer. For neighborhoods, we looked at zip codes and those that had different poverty levels. This was based on United States census data from 2014. Families that had greater than 20% of persons living below the federal poverty level were considered high poverty, and those with less than 20% were considered low poverty. That was how we proxied those 2 variables in this study.

There was really no difference in EFS and OS based on race, ethnicity, or socioeconomic determinants of health in terms of frontline therapy. However, when patients relapsed, we found that [non-Hispanic] Black children experienced statistically significantly inferior post-relapse survival. This study is going to spawn [further assessment of] the cohort of patients who have relapsed osteosarcoma and why they have worse outcomes.

Why were patients with non-metastatic disease specifically evaluated?

[We looked at this group] because it's a cleaner cohort. Within metastatic disease, there's bone, bone relapse, lung relapse, and a variety of other variables involved that are harder to control, [making this] cohort cleaner.

We also wanted to use the [EURAMOS-1] trial, which was a non-metastatic study [conducted] in patients 5 to 21 years of age. This is because we didn't want to [account for] adult lifestyles and migration. [The original] study enrolled patients [older than 21], but we evaluated the [pediatric] cohort.

What are the clinical implications of these results, and how might they inform future research in osteosarcoma?

I was pleasantly surprised that, irrespective of poverty level, these patients had comparable EFS [rates]; that's [not the case for] a lot of the cancers. We have shown a striking difference in [survival] outcomes in many adult cancers, so this is good news. It means that children's cancer care is much more inclusive and accessible to people from all different socioeconomic backgrounds. However, it also shines a light on the point that the ability of patients [experiencing] relapse to get excellent access to care is somewhat compromised.

[Our next steps] are to drill down on patients [who relapse] and see which ways we can do better in terms of improving their outcomes.

What do you hope colleagues who treat adult patients with nonmetastatic osteosarcoma take away from these findings?

For those who do not treat pediatric patients, the message here is that the COG does a good job of improving access [to care], and there may be some lessons learned there. However, socioeconomic disparities are omnipresent throughout all our patient populations, whether it's for the primary or secondary treatment of [patients with] cancer. We need to be vigilant about making sure that we [evaluate] socioeconomic disparities and determinants of health. [We must] provide access to the best treatments to patients from all walks of life.

Reference

Ilcisin L, Han R, Krailo M, et al. Poverty, race, ethnicity, and survival in pediatric nonmetastatic osteosarcoma: a Children’s Oncology Group report. J Natl Cancer Inst. 2024;(00):1–11. doi:10.1093/jnci/djae103.