Does where you live influence how your vestibular schwannoma is managed? Examining geographical differences in vestibular schwannoma treatment across the United States

Abstract

The management of small- to medium-sized vestibular schwannoma (VS) remains controversial. Despite a lack of compelling evidence supporting one treatment modality over others, many providers and institutions remain highly biased toward one particular therapy-microsurgery, radiation, or primary observation. The objective of the current study was to estimate the impact of geography on disease presentation and initial treatment of VS in the United States. An analysis of the Surveillance, Epidemiology, and End Results (SEER) database identified 9761 patients with VS that were managed across the 16 SEER geographic registry areas. Univariate analyses demonstrated strong associations between geographic location and tumor size at diagnosis (P < 0.0001). When analyzing the 6115 subjects with tumors between 0 and 3 cm in size, multivariable models identified strong associations between place of residence and treatment modality (P < 0.0001). These multivariable models demonstrated that in many cases the impact of place of residence on treatment selection was greater than other established variables such as tumor size and age. To our knowledge, this is the first study to evaluate geographic trends in VS patient demographics, tumor size and management in the United States. These data suggest that disease presentation and treatment modality are significantly influenced by regional referral patterns, provider or institutional treatment preferences, and regional availability of subspecialty expertise. Understanding geographic bias is important for patients, referring physicians, and treatment providers alike. Until there is clear evidence supporting one therapy over others, multidisciplinary consultation with a minimum of a neurotologist, neurosurgeon, and radiation oncologist or radiosurgeon should be offered in order to provide balanced counseling and accurate informed consent.

The Impact of Radiation Oncologists on the Early Adoption of Hypofractionated Radiation Therapy for Early-Stage Breast Cancer

“…The importance of the radiation oncologist is similarly reflected in this article. Most previous work has focused on assessing the impact of surgeons on treatment patterns such as mastectomy for breast cancer (38)(39)(40)(41) or active surveillance in prostate cancer (37,42), or primary treatment of vestibular schwannoma (43). Therefore, both this article and the previous report by Jagsi et al (15) represent a novel approach in understanding treatment decisionsdby assessing the impact of the radiation oncologistdand they suggest an increasing need for research, especially because the relative increase in nationwide health care expenditures in radiation oncology far outpaces that in other medical specialties (44).…”

An international comparison of diagnostic and management strategies for vestibular schwannoma

“…The study described place of residence as a stronger predictor for choice of management strategy than a patient’s age or VS size [12]. Next to referral patterns and availability of care, the authors contribute this to provider or institutional preference [12]. Naturally, in the current study, the proportion of patients assigned to each management strategy can be partially attributed to differences in local availability of care and referral patterns.…”

“…The study described place of residence as a stronger predictor for choice of management strategy than a patient’s age or VS size [12]. Next to referral patterns and availability of care, the authors contribute this to provider or institutional preference [12].…”

Geographic distribution of vestibular schwannomas in West Scotland between 2000-2015

“…Stepanidis et al (2014) demonstrated a decrease in diagnosis of VS in remote areas of Denmark due to lower rates of reporting [48]. Better links between primary and tertiary care might well result in higher diagnostic rates of VS. Carlson et al (2016) found that geographic location impacts both VS presentation and treatment because of variability in regional referral patterns, “provider or institutional treatment preferences, and regional availability of subspecialty expertise” [21]. On the other hand, one could argue that such variabilities should not be very common within the standardized context of NHS; therefore the increased period prevalence observed in some predominantly rural areas of Scotland could well be real.…”

“…Only one recent study in the United States has examined the association between geographic variables and differences the treatment strategy of VS using a cohort of 9761 VS cases over an eight-year period [21]. That study, however, utilized spatially disjunct regions for analysis and did not examine the spatial distribution or pattern of VS across the US.…”