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INTERSECTION OF RACE AND SOCIOECONOMIC STATUS WITH PATHOLOGIC RESPONSE AFTER NEOADJUVANT THERAPY FOR PDAC
K K. Akinola
*, Victor Perim, Chandler McLeod, Herbert Chen, Smita Bhatia, J B. Rose, Andrea Gillis
University of Alabama at Birmingham, Birmingham, AL
Background: Pancreatic adenocarcinoma (PDAC) has poor outcomes, worsened by racial disparities, with Black patients experiencing lower overall survival compared to their White peers. Lower socioeconomic status, including public insurance and poverty, is also linked to lower survival in PDAC. Limited research exists on the association of racial and socioeconomic disparities with significant pathologic response (SPR) after neoadjuvant therapy (NAT) as a potential link to impaired survival.
Methods: Using the National Cancer Database (NCDB), we analyzed patients 18+ years with PDAC (ICD-0-3 histology codes: 8140 & 8500) who underwent NAT and pancreatic resection from 2018 to 2022. Patients with missing race were excluded. SPR was defined as ypT0 or ypTis plus ypN0 and cM0. The primary outcome was SPR incidence. Overall survival (OS) and 30-day mortality were secondary outcomes. Univariable (UVA), multivariable (MVA), and Cox proportional hazard (CoxPH) analyses were done, controlling for demographics, clinical staging, chemotherapy type, patient insurance status, median neighborhood household income (1
st quartile: <$46,277, 4
th quartile: >$74,063), and median household educational status based on zip code. P-values < 0.05 were considered significant.
Results: A total of 8,827 patients were included. Racial/ethnic breakdown was 7,216 (81.7%) non-Hispanic White (NHW), 860 (9.7%) non-Hispanic Black (NHB), 277 (3.1%) non-Hispanic Asian (A), and 474 (5.4%) Hispanic (H). The mean age was 65.5 years (SD 9.4), with 4,462 (50.5%) male. A total of 302 (3.4%) patients achieved SPR, including 240 (79.5%) NHW, 34 (11.3%) NHB, 17 (5.6%) Hispanics and 11 (3.6%) Asians. The insurance breakdown was 3,187 (36.1%) private, 64 (0.73%) Unknown, 671 (7.6%) Medicaid, 4,790 (54.3%) Medicare, and 110 (1.25%) Uninsured. UVA showed no significant association between SPR and race (NHB OR 1.20, p=0.33; Asian OR 1.20, p=0.56; Hispanic OR 1.08, p=0.76), education (OR 1.29, p=0.64), insurance (Medicaid OR 0.89, p=0.62; Medicare OR 0.83, p=0.13), or income (OR 1.04, p=0.83). MVA CoxPH for survival showed Asians with better OS (HR 0.64, p<0.01) compared to NHW, but no such association for NHB (HR 0.89, p=0.17) or Hispanics (HR 0.92, p=0.43). A race-stratified MVA Cox PH predicting survival showed NHW patients with Medicaid (HR 1.44, p<0.001) and Medicare (HR 1.33, p<0.001) had worse survival compared to NHW patients with private insurance; other races did not have significant associations with insurance.
Conclusion: Racial and socioeconomic disparities did not predict SPR in PDAC patients undergoing NAT and surgery. However, the intersection of insurance status, race, and socioeconomic factors influenced survival. Among NHW patients, Medicaid/Medicare was linked to worse survival, suggesting insurance status had a greater impact than race.
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