Impact of Rurality on Treatment and Survival in Patients with Brain Metastases
Thomas Khodadad1, Elizabeth Wicks2, Alissa Thomas3
1The Robert Larner College of Medicine at the University of Vermont, 2Department of Neurosurgery, 3Department of Neurological Sciences, University of Vermont Medical Center
Objective:
To evaluate the impact of rurality on survival outcomes, access to specialty consultation, and treatment for patients with newly diagnosed brain metastases receiving treatment in Vermont.
Background:
Disparities in healthcare access and outcomes between rural and urban populations are well-documented, but limited data exists for patients with brain metastases.
Design/Methods:
A single-institution retrospective cohort study was conducted on 223 patients diagnosed with brain metastases from 2020 to 2022. Rurality was classified using US Department of Agriculture Urban-Rural Continuum Codes. Statistical analysis was performed using R.
Results:
Among 223 patients, 112 were urban and 111 rural. Demographics were similar (50% women in urban vs 39% in rural; median age 64.7 vs 63.7 years; median KPS 80 vs 70). NSCLC was more common in urban patients (52.7%, 30.5%, p=0.0044), while breast cancer (13.4%, 10.6%), melanoma (6.25%, 6.4%), and other tumor types (27.7% vs. 19.9%) showed no significant differences. Urban patients were more likely to receive brain-directed chemotherapy (30.4% vs 14.2%, p=0.0046), but rates of surgery, stereotactic radiosurgery, whole brain radiation, and systemic therapy did not differ significantly. Consultations with palliative care (49.1%, 43.3%), neuro-oncology (38.4%, 28.4%), neurosurgery (39.3%, 33.3%), and radiation oncology (96.4%, 73%) were comparable.
Median overall survival was 194 days for the cohort, and 258.5 vs 142 days for urban patients and rural patients, respectively. The time-varying Cox model demonstrated the hazard for rural patients increased more rapidly over time (HR = 1.406, p = 0.0182), and between 360 and 540 days, rural patients had a significantly increased risk of death compared to urban patients (rural HR increased by 45%; p<0.05 for this period).
Conclusions:
Urban patients with brain metastases experienced better survival outcomes, despite similar treatment and consultation rates. Further investigation into systemic disease status and comorbidities is needed to explain these survival differences.
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