Socioeconomic and Racial Disparities Affect Access to High-Volume Centers During Meningioma Treatment.

BACKGROUND: Studies examining the relationship among hospital case volume, socioeconomic determinants of health, and patient outcomes are lacking. We sought to evaluate these associations in the surgical management of intracranial meningiomas. METHODS: We queried the National Inpatient Sample (NIS) database for patients who underwent craniotomy for the resection of meningioma in 2013. We categorized hospitals into high-volume centers (HVCs) or low-volume centers (LVCs). We compared outcomes in 2016 to assess the potential impact of the Affordable Care Act on health care equity. Primary outcome measures included hospital mortality, length of stay, complications, and disposition. RESULTS: A total of 10,270 encounters were studied (LVC, n = 5730 [55.8%]; HVC, n = 4340 [44.2%]). Of LVC patients, 62.9% identified as white compared with 70.2% at HVCs (P < 0.01). A higher percentage of patients at LVCs came from the lower 2 quartiles of median household income than did patients at HVCs (49.9% vs. 44.2%; P < 0.001). Higher mortality (1.3% vs. 0.9%; P = 0.041) was found in LVCs. Multivariable regression analysis showed that LVCs were significantly associated with increased complication (odds ratio, 1.36; 95% confidence interval, 1.30-1.426, P<0.001) and longer hospital length of stay (odds ratio, -0.05; 95% confidence interval, -0.92 to -0.45; P <0.001). There was a higher proportion of white patients at HVCs in 2016 compared with 2013 (67.9% vs. 72.3%). More patients from top income quartiles (24.2% vs. 40.5%) were treated at HVCs in 2016 compared with 2013. CONCLUSIONS: This study found notable racial and socioeconomic disparities in LVCs as well as access to HVCs over time. Disparities in meningioma treatment may be persistent and require further study.

Non-English Primary Language Is Associated with Short-Term Outcomes After Supratentorial Tumor Resection.

BACKGROUND: Despite research indicating that patients with non-English primary language (NEPL) have increased hospital length of stay (LOS) for craniotomies, there is a paucity of neurosurgical research examining the impact of language on short-term outcomes. This study sought to evaluate short-term outcomes for patients with English primary language (EPL) and NEPL admitted for resection of a supratentorial tumor. METHODS: Using the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project New Jersey State Inpatient Database, this study included patients 18-90 years old who underwent resection of a supratentorial primary brain tumor, meningioma, or brain metastasis from 2009 to 2017. The primary outcomes were total, preoperative, and postoperative LOS. Secondary outcomes were complications, mortality, and discharge disposition. Univariable and multivariable analyses compared Spanish primary language (SPL), non-English non-Spanish (NENS) primary language, and EPL groups. RESULTS: A total of 7324 patients were included: 2962 with primary brain tumor, 2091 with meningioma, and 2271 with brain metastasis. Patients with SPL (n = 297) were younger and more likely to have noncommercial insurance, lower income, and fewer comorbidities. Patients with NENS (n = 257) had similar age and comorbidities to the EPL group but had a greater proportion of noncommercially insured and low-income patients (P < 0.001). Multivariable analysis showed that patients with NENS had increased postoperative LOS (adjusted incidence rate ratio, 1.10; P = 0.008) and higher odds of a complication (adjusted odds ratio, 1.36; P = 0.015), and patients with SPL had higher odds of being discharged home (adjusted odds ratio, 1.55; P = 0.017). CONCLUSIONS: Patients with NEPL have different short-term outcomes after supratentorial tumor resection that varies based on primary language. More research is needed to understand the mechanisms driving these findings and to clarify unique experiences for different populations with NEPL.

Incidence of Benign Meningiomas in the United States: Current and Future Trends.

Background: Benign meningiomas are the most frequently reported central nervous system tumors in the United States, with increasing incidence in past decades. However, the future trajectory of this neoplasm remains unclear. Methods: We analyzed benign meningioma incidence of cases identified by any means (eg, radiographically with or without microscopic confirmation) in US Surveillance, Epidemiology, and End Results cancer registries among groups aged 35 to 84 years during 2004-2017 by sex and race and ethnicity using age-period-cohort models. We employed age-period-cohort forecasting models to glean insights regarding the etiology, distribution, and anticipated future (2018-2027) public health impact of this neoplasm. Results: In all groups, meningioma incidence overall increased through 2010, then stabilized. Temporal declines were statistically significant overall and in most groups. JoinPoint analysis of cohort rate-ratios identified substantial acceleration in White men born after 1963 (from 1.1% to 3.2% per birth year); cohort rate-ratios were stable or increasing in all groups and all birth cohorts. We forecast that meningioma incidence through 2027 will remain stable or decrease among groups aged 55-84 years but remain similar to current levels among groups aged 35-54 years. The case count of total meningioma burden in 2027 is expected to be approximately 30 470, similar to the expected case count of 27 830 in 2018. Conclusions: Between 2004 and 2017, overall incidence of benign meningioma increased and then stabilized or declined. For 2018-2027, our forecast is incidence will remain generally stable in younger age groups but decrease in older age groups. Nonetheless, the total future burden will remain similar to current levels because the population is aging.

Association between Airport-Related Ultrafine Particles and Risk of Malignant Brain Cancer: A Multiethnic Cohort Study.

Ultrafine particles (UFP; diameter less than or equal to 100 nm) may reach the brain via systemic circulation or the olfactory tract and have been implicated in the risk of brain tumors. The effects of airport-related UFP on the risk of brain tumors are not known. Here we determined the association between airport-related UFP and risk of incident malignant brain cancer (n = 155) and meningioma (n = 420) diagnosed during 16.4 years of follow-up among 75,936 men and women residing in Los Angeles County from the Multiethnic Cohort study. UFP exposure from aircrafts was estimated for participants who lived within a 53 km × 43 km grid area around the Los Angeles International Airport (LAX) from date of cohort entry (1993-1996) through December 31, 2013. Cox proportional hazards models were used to estimate the effects of time-varying, airport-related UFP exposure on risk of malignant brain cancer and meningioma, adjusting for sex, race/ethnicity, education, and neighborhood socioeconomic status. Malignant brain cancer risk in all subjects combined increased 12% [95% confidence interval (CI), 0.98-1.27] per interquartile range (IQR) of airport-related UFP exposure (∼6,700 particles/cm3) for subjects with any address in the grid area surrounding the LAX airport. In race/ethnicity-stratified analyses, African Americans, the subgroup who had the highest exposure, showed a HR of 1.32 (95% CI, 1.07-1.64) for malignant brain cancer per IQR in UFP exposure. UFP exposure was not related to risk of meningioma overall or by race/ethnicity. These results support the hypothesis that airport-related UFP exposure may be a risk factor for malignant brain cancers. SIGNIFICANCE: Malignant brain cancer risk increases with airport-related UFP exposure, particularly among African Americans, suggesting UFP exposure may be a modifiable risk factor for malignant brain cancer.

Demographic and socioeconomic disparities of benign cerebral meningiomas in the United States.

Epidemiology provides an avenue for deciphering disease pathogenesis. By determining incidence across socioeconomic and demographic variables in the context of benign cerebral meningiomas (BCM), epidemiologic data may aid in elucidating and addressing healthcare inequalities. To investigate BCM incidence (per 100,000) with respect to sex, age, income, residence, and race/ethnicity, we queried the largest United States (US) administrative dataset (1997-2016), the National (Nationwide) Inpatient Sample (NIS), which surveys 20% of US discharges. Annual national BCM incidence was 5.01. Females had an incidence of 6.78, higher (p = 0.0000038) than males at 3.14. Amongst age groups incidence varied (p = 1.65 × 10-11) and was highest amongst those 65-84 (16.71) and 85+ (18.32). Individuals with middle/high income had an incidence of 5.27, higher (p = 0.024) than the 4.91 of low income patients. Depending on whether patients lived in urban, suburban, or rural communities, incidence varied (χ2 = 8.22, p = 0.016) as follows, respectively: 5.23; 4.96; 5.51. Amongst race/ethnicity (p = 8.15 × 10-14), incidence for Whites, Blacks, Asian/Pacific Islanders, Hispanics, and Native Americans were as follows, respectively: 5.05; 4.59; 4.22; 2.99; 0.55. In the US, BCM annual incidence exhibited disparities amongst socioeconomic and demographic subsets. Disproportionately, incidence was greatest for patients who were White, Black, female, 65 and older, and middle/high income.

The epidemiology of patients undergoing meningioma resection in Auckland, New Zealand, 2002 to 2011.

The incidence of meningioma is known to vary by gender and ethnicity. This study aimed to describe the epidemiological characteristics of a 10-year cohort of patients undergoing meningioma resection at Auckland City Hospital, Auckland, New Zealand. Of particular interest was whether there was any difference in meningioma incidence and recurrence rates between New Zealand Maori and Pacific Island patients compared with other ethnic groups. The study was a retrospective analysis of 493 patients with pathologically confirmed meningioma over the period 1 January 2002 to 31 December 2011. Based on this neurosurgical cohort, the minimum incidence of meningioma in the Auckland region was 3.39 per 100,000 population per year (95% C.I. 3.02-3.80) for the study period. Meningioma was significantly more common in women than men by a ratio of 4.2:1. New Zealand Maori and Pacific Island patients had a significantly higher incidence of meningioma than other ethnic groups. New Zealand Maori had a meningioma incidence 2.74 times that of Europeans (95% C.I. 2.01-3.73, p < 0.001). Pacific Island patients had 2.03 times higher incidence of meningioma than Europeans (95% C.I. 1.42 - 2.89, p < 0.001). The overall meningioma recurrence rate was 21.6% with a mean follow-up of 77 months. Recurrence rates for meningioma among Pacific Island patients were significantly higher than for other ethnic groups (hazard ratio 1.73, p = 0.008). Multivariate analysis of clinical variables confirmed the significance of traditional prognostic factors such as WHO tumour grade and Simpson grade of surgical excision in predicting meningioma recurrence.

Association of Race with Survival in Intracranial World Health Organization Grade II and III Meningioma in the United States: Systematic Literature Review.

BACKGROUND: Recent literature has shown significant differences in meningioma incidence among different races, but minimal conclusive data exist on the role of race and ethnicity in overall survival for patients with high-grade intracranial meningioma. We conducted a systematic review to investigate the impact of race and ethnicity on survival in patients with high-grade intracranial meningioma. METHODS: A systematic literature review was conducted for studies using Ovid, PubMed, Cochrane, Embase, and Scopus databases. Databases were queried for the following: Meningioma AND [Ethnic OR Demography, OR African American OR Arab OR Hispanic OR Asian, OR White OR race OR racial] AND [survival OR survival analysis OR survival rate OR treatment outcome OR Survivor OR Outcome]. RESULTS: A literature search yielded a total of 412 abstracts, which were screened according to criteria that were determined a priori, and a total of 129 full-text articles were reviewed. Four articles were included in the final analysis, reporting on a total of 13,424 patients. Three studies saw an overall survival benefit in White non-Hispanics compared with Black non-Hispanics, and 1 reported a survival benefit in White non-Hispanics and Black non-Hispanics among patients who received gross total resection. One study additionally reported an increased likelihood of White patients receiving gross total resection when compared with non-White patients. CONCLUSIONS: The limited data available suggest that White patients have improved measures of survival compared with nonw-White patients, for reasons that are likely complex and multifactorial. Further studies are needed to explore these survival differences seen.

Demographic profile of patients diagnosed with intracranial meningiomas in two academic hospitals in Johannesburg, South Africa: a 12-month prospective study.

BACKGROUND: Meningiomas are common brain tumours and display gender, racial and ethnic differences in their demographic profile. The demographic profile of our patients diagnosed with intracranial meningiomas is presented and compared with the literature. OBJECTIVES: To determine the age, gender, racial and ethnic distribution of our patients diagnosed with intracranial meningiomas. METHODS: Consecutive patients (48 in number) seen at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and Chris Hani Baragwanath Academic Hospital (CHBAH), Johannesburg, with histologically proven meningiomas over a 12 month period were recruited for the study. RESULTS: Meningiomas accounted for 33.8% of all primary brain tumours. The mean age of patients was 45.7 ± 10.5 years with a female-to-male ratio of 3.8:1. The mean age for male patients was 39.3 ± 13.5 years while that of female patients was 47.4 ± 9.0 years. The peak age range at presentation was in the fifth (41.7%) decade. The highest frequency was among Black Africans (75%) and Sotho ethnic nationality (27.1%). CONCLUSION: The study showed a female preponderance for intracranial meningiomas among our patients. Although intracranial meningiomas were more in frequency among Black Africans, the racial distribution mirrored our population distribution while the highest frequency was among Sotho ethnic nationality.

Association study on MTHFR polymorphisms and meningioma in northern China.

BACKGROUND: Meningioma is the second most common primary tumor of the central nervous system, and multiple genetic and environmental factors contribute to its etiology. Methylene tetrahydrofolate reductase (MTHFR) is a pivotal enzyme in folate metabolism. We conducted a case-control study to investigate the association of the MTHFR gene and meningioma in a Han population in northern China. METHODS: We genotyped two SNPs (C677T and A1298C) using polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP). In this study 317 meningioma patients were compared to 320 normal controls. Data were analyzed by SPSS 13.0 and HaploView software. RESULTS: We found a significant difference in the frequency distribution of 677CC and 677TT between cases and control groups; another SNP exhibited no differences in any genotype between the two cohorts. CONCLUSION: The results revealed that variations of the MTHFR gene were associated with meningioma; this finding indicates that the MTHFR gene potentially plays an important role in the pathogenesis of meningioma in the Northern Chinese Han population.

Epidemiology of primary brain tumors in the Middle Eastern population in California, USA 2001-2005.

BACKGROUND: The fast growing Middle Eastern (ME) population has rarely been studied in the U.S.. The purpose of this study was to compare the epidemiology of primary brain tumors in this ethnic population with the non-Hispanic, non-Middle Eastern White (NHNMW) in California. METHODS: ME cases were identified by surname in the California cancer registry and ME population estimates were based on ancestry. Data for 683 cases of primary brain tumors (429 benign, 238 malignant, 16 uncertain) in the ME and 15,589 cases (8352 benign, 6812 malignant, 425 uncertain) in the NHNMW were available for this study. RESULTS: ME patients were significantly (p < 0.05) younger and their age-adjusted incidence rates per 100,000 for benign tumors of 10.0 in men and 17.6 in women were higher than similar rates of 7.3 and 10.6 in the NHNMW group (p < 0.05). Rates for malignant tumors were similar. Meningioma was the main histology responsible for the observed increase in patients over 40 years of age. Also increased were benign tumors of the pituitary and pineal glands. The overall mortality in patients with benign tumors was significantly lower than malignant tumors. CONCLUSIONS: This study presents a significantly high incidence of benign meningioma in the ME population in California. This may be due to higher susceptibility or exposure of this ethnic group to the risk factor(s) for this neoplasm. Considering the reported causal association of benign meningioma with childhood radiation exposure from Israel, exposure to this risk factor in this ethnic group needs to be evaluated in future studies.

Meningiomas and the Polynesian population.

BACKGROUND: In Auckland Hospital, New Zealand there has been a perception for many years that the incidence of meningiomas was higher in Polynesians. It was also suspected these occurred at a younger age in Polynesians and were more likely to be multiple. The purpose of the present study was to confirm whether the Polynesian population does have a higher incidence of meningioma, review at what age they presented with meningioma and compare the outcome of treatment with Caucasians. METHODS: A retrospective review was performed of 302 patients who had had a cranial meningioma excised in the 10 years between 1991 and 2001 at Auckland hospital. Age, sex, ethnicity, number of tumours, type, size, comorbidities, time to presentation and outcome at discharge and follow-up were recorded. RESULTS: Polynesians had a significantly higher incidence of meningiomas (P < 0.0001). In particular Polynesian women were significantly over represented. (P < 0.05). Polynesians were more likely to have two or more tumours (P < 0.02) and they presented at a significantly younger age (P < 0.0001). The tumours were also larger. (P = 0.0006). Despite this Polynesians did not have a worse outcome at discharge or at follow up (P > 0.1) nor did they have a higher incidence of comorbidites, perhaps reflected by their younger age. CONCLUSIONS: There is a higher incidence of meningiomas in the Polynesian population, particularly young Polynesian women. The tumours are more likely to be multiple and larger in Polynesians. The present study confirms a predisposition to meningioma in New Zealand Polynesians and should lead to further investigation into whether this is genetic (likely chromosome 22) or hormonal possibly mediated by insulin-like growth factor-1.

Retrospective epidemiologic analysis of patients diagnosed with intracranial meningioma from 1977 to 1990 at the Jackson Memorial Hospital, Sylvester Comprehensive Cancer Center: the Jackson Memorial Hospital Tumor Registry experience.

A descriptive analysis was performed of the Tumor Registry data for intracranial meningioma by the Jackson Memorial Hospital, University of Miami School of Medicine Tumor Registry. A total of 108 cases of intracranial meningioma was collected and reviewed. Overall survival for 2, 5, and 10 years was 82, 72, and 60%, respectively. There was no difference in survival for males and females at 5 years, nor any difference in survival for race or ethnicity. There was a trend for improved survival for the young age group (18-55 years).

Descriptive epidemiology of primary cancer of the brain, cranial nerves, and cranial meninges in New Zealand, 1948-88.

We used New Zealand data on occurrence of different types of brain cancer to investigate: (i) a possible secular increase which has been seen worldwide and has generated considerable debate; (ii) possibly higher rates among Maori; and (iii) possibly higher risks related to social class and occupation. Data from the NZ Cancer Registry on the 5,684 brain cancers diagnosed among NZ residents from 1948-88 were used to study the pattern of occurrence by gender, age, race, calendar year, social class, occupation, and histology. Age-standardized brain-cancer incidence rates per 100,000 more than doubled over the 41-year period (from 2.9 to 6.9 in males and from 2.1 to 5.1 in females). A strong trend of increasing incidence with increasing social class is seen in males (Ptrend = 0.01). Among Maori, the proportion of all brain cancer that is medulloblastoma is four times that among non-Maori, and the proportion of all brain cancers that lack histologic confirmation is about 40 percent higher. Elevated risks are seen among: dairy farmers (odds ratio [OR] = 3.4, 95 percent confidence interval [CI] = 1.9-6.0); sheep handlers (OR = 2.7, CI = 1.4-5.3); livestock workers (OR = 3.8, CI = 1.7-8.4); and farm managers (OR = 3.2, CI = 1.4-7.2); as well as among electrical engineers (OR = 8.2, CI = 20-34.7); electricians (OR = 4.6, CI = 1.7-12.2); and other electrical workers. Brain cancer rates in NZ have increased steadily since 1948, but this increase has leveled off in the most recent five-year period. Although brain cancer rates are likely to be underestimated among the Maori, an excess of medulloblastoma is evident in this group.

Brain tumors diagnosed in the first year of life in five Far-Eastern countries. Statistical analysis of 307 cases.

A statistical survey is presented of brain tumors diagnosed in the first year of life (from five Far-Eastern countries) in relation to the racial differences in tumor types, congenital factors, and general clinical features. Of the 307 cases collected, 262 were verified histologically, and astrocytomas comprised 23.3%, medulloblastomas 17.2%, ependymomas 11.1%, choroid plexus papillomas 10.7%, teratomas 8.4%, primitive neuroectodermal tumors 4.2%, meningiomas 2.3%, and others 22.9%. There were statistically significant racial differences in comparison with the worldwide survey done by the International Society for Pediatric Neurosurgery Education Committee (1987) on the same subject. In the Far-Eastern population, medulloblastoma and teratoma were more common (P less than 0.05), whereas astrocytoma was less frequent (P less than 0.01) than reported in the worldwide survey. The malformative factors were suggested in 18 cases in which various associated congenital anomalies were observed. Vascular anomalous lesions, mostly in the extracranial organs, were most common, comprising 61.1% of the associated malformations. Hereditary factors were less commonly demonstrated in these tumors than were anomalies in the major congenital central nervous system. Among the 307 cases, there was one instance (0.3%) of nearly identical tumors occurring in twin brothers. The specific clinical manifestations of brain tumors involving the immature brain were again apparent in this survey, as were the poor survival rates and poor functional prognosis.

Descriptive epidemiology of primary tumors of the spinal cord and spinal meninges in Los Angeles County, 1972-1985.

This report presents data on the distribution of 462 primary tumors of the spinal cord and spinal meninges (both benign and malignant) diagnosed among residents of Los Angeles County from 1972 to 1985. Incidence rates of gliomas, meningiomas, nerve sheath tumors, and all histologic types combined are presented for specific age, sex, and ethnic groups. The highest rates are seen for meningiomas in women (age-adjusted rate 3/million/year compared to 1/million/year for the other two histologic types in women and for each of the three types in men). Proportional incidence ratios for spinal tumors are elevated among men and women born in Eastern Europe and among Jewish residents of Los Angeles County. The incidence rates appear not to relate to the social class.

Steroid hormone receptors in meningiomas of Chinese patients.

Meningioma is a hormone-related intracranial tumor. Brain tumor samples were collected from 32 Chinese patients, 20 of whom had meningiomas. Estrogen receptors were present in 6 of 17 meningiomas, 1 hemangioblastoma, 1 gemistocytic astrocytoma, and 1 neurilemoma. Of the 26 samples assayed for progesterone receptors, measurable bindings were found in 14 of 17 meningiomas, 1 of 2 astrocytomas, 1 malignant lymphoma, 1 hemangioblastoma, 1 ganglioglioma, 1 glioblastoma multiforme, 1 anaplastic ependymoma, 1 small cell sarcoma, and 1 neurilemoma. Androgen receptors were found in 8 of 19 meningiomas, but not in the 11 other brain tumors examined. Measurable glucocorticoid receptors were found in 15 of 19 meningiomas, 1 malignant lymphoma, 1 hemangioblastoma, 2 craniopharyngiomas, 1 neurilemoma, 1 of 2 glioblastomas, and 1 of 2 astrocytomas. Of the 10 samples examined for tyrosine aminotransferase activity, measurable enzyme activity was found in 7 of the 8 meningiomas, but not in the single hemangioblastoma nor in the single craniopharyngioma. In accordance with other published studies, the results from this study also suggest that the growth of meningiomas may be regulated by hormones, and that the role steroid hormones and their receptors play in the meningioma is worthy of further investigation.

Descriptive epidemiology of primary tumors of the brain, cranial nerves and cranial meninges in Los Angeles County.

This report presents data on the distribution of 8,612 cases of primary tumors of the brain, cranial nerves and cranial meninges (both benign and malignant) diagnosed among residents of Los Angeles County from 1972 to 1985. Incidence rates of gliomas, meningiomas, nerve sheath tumors and all histologic types combined are presented for specific age, sex and ethnic groups. At all ages, the highest incidence is seen for gliomas among men. Meningioma rates are higher among women than men in every ethnic group. In both sexes, glioma rates are highest among whites, and meningioma rates are highest among blacks. Asians have the lowest rates of both types of tumors. Proportional incidence ratios are elevated among those born in Eastern Europe, Southern Europe and the Middle East and among Jewish residents of Los Angeles County. A clear trend of increasing glioma incidence with increasing social class is seen among males. An analysis among white men aged 25-64 by occupation and industry at the time of diagnosis supports several previously published findings. A glioma excess is evident among workers in the aircraft industry. Workers in the petroleum industry and the rubber and plastics industry have an excess of meningiomas. Occupational groups at excess risk include dentists who have an increased risk of all types of brain tumors and electricians whose excess risk is limited to gliomas.