BACKGROUND The published reports examining socioeconomic factors and their relationship to osteosarcoma presentation and treatment suggest an association between lower socioeconomic status and a worse response to chemotherapy and lower survivorship. However, the driving factors behind these disparities are unclear. The Child Opportunity Index was developed by diversitydatakids.org (https://www.diversitydatakids.org/) in 2014 to cumulatively quantify social determinants of health in an index specifically tailored toward a pediatric population and organized by census tract. The Childhood Opportunity Index can be used to explore the relationship between a patient's socioeconomic background and disparities in osteosarcoma presentation, treatment, and outcomes. QUESTION/PURPOSES Are differences in a child's Childhood Opportunity Index score associated with differences in (1) time from symptom onset to first office visit for osteosarcoma, (2) timing of chemotherapy or timing and type of surgical resection, or (3) initial disease severity, development of metastatic disease, or overall survival? METHODS A retrospective therapeutic study was conducted using data drawn from the institutional records of a large pediatric tertiary cancer center located in the Mid-Atlantic region of the United States from the years 2006 to 2022. Our main site is in an urban setting, with ample access to public transit. Patients were excluded from analysis if they were seeking a second opinion or our institution was not the main point of orthopaedic care (24% [54 of 223]), had incomplete electronic medical records (4% [9 of 223]), resided in an international country (3% [7 of 223]), presented after relapse (3% [7 of 223]), or lacked 2 years of follow-up at our institution (2% [4 of 223]). A total of 113 pediatric patients (children younger than 18 years) met the inclusion criteria. The Child Opportunity Index is a composite index derived from three domains (education, health and environment, and social and economic) and 29 indicators within the domains that serve to capture the cumulative effect of disparities on child well-being. National Childhood Opportunity scores were collected and scored from 1 to 100. Each score represents an equal proportion of the US population of children 18 years of age or younger. A higher number indicates higher levels of socioeconomic opportunity. The overall Childhood Opportunity Index score was then broken down into three groups representative of the child's relative socioeconomic opportunity: lowest tertile for scores < 34, middle tertile for scores between 34 and 66, and highest tertile for scores > 66. Means, ranges, medians, IQRs, and percentages were used to describe the study sample. Data analysis was conducted across the three groups (lowest tertile, middle, and highest), assessing differences in time to presentation, treatment variations, disease severity, and overall survivorship. Chi-square and Fisher exact tests were applied to compare categorical variables. Mann-Whitney U tests compared continuous data. Kaplan-Meier survival analysis, stratified by Childhood Opportunity Index tertile, was performed for a 5-year period to evaluate the development of metastatic disease and overall survivorship. A log-rank test was applied to evaluate statistical significance. Due to the small sample size, we were unable to control potential confounders such as race and insurance. However, the three domains (education, health and environment, and social and economic) encapsulated by the Childhood Opportunity Index data indirectly account for disparities related to race and insurance status. RESULTS There was no association between lower levels of socioeconomic opportunity, as expressed by the lack of difference between the Childhood Opportunity Index tertiles for the interval between symptom onset and first office visit (mean ± SD lowest tertile 77 ± 67 days [95% confidence interval (CI) 60 to 94], middle tertile 69 ± 94 days [95% CI 50 to 89], and highest tertile 56 ± 58 days [95% CI 41 to 71]; p = 0.3). Similarly, we found no association between lower levels of socioeconomic opportunity, as expressed by the lack of difference between the Childhood Opportunity Index tertiles and the time elapsed from the first office visit to the first chemotherapy session (lowest tertile 19 ± 12 days [95% CI 12 to 26], middle 19 ± 14 days [95% CI 11 to 26], and highest 15 ± 9.7 days [95% CI 8.4 to 21]; p = 0.31), the time to surgical resection (lowest tertile 99 ± 35 days [95% CI 87 to 111], middle 88 ± 28 days [95% CI 77 to 99], and highest 102 ± 64 days [95% CI 86 to 118]; p = 0.24), or the type of surgical resection (limb-sparing versus amputation: 84% [21 of 25] in lowest tertile, 83% [24 of 29] in the middle tertile, and 81% [48 of 59] in the highest tertile received limb-sparing surgery; p = 0.52). Finally, we found no differences in terms of disease-free survival at 5 years (lowest tertile 27% [95% CI 7.8% to 43%], middle 44% [95% CI 23% to 59%], and highest 56% [95% CI 40% to 67%]; p = 0.22), overall survival (lowest 74% [95% CI 58% to 95%], middle 82% [95% CI 68% to 98%], and highest 64% [95% CI 52% to 78%]; p = 0.27), or in terms of survivorship of the cohort, excluding patients who presented with metastatic disease (lowest 84% [95% CI 68% to 100%], middle 91% [95% CI 80% to 100%], and highest 68% [95% CI 55% to 83%]; p = 0.10). CONCLUSION In our single-center retrospective study of 113 children who presented with osteosarcoma, we did not find an association between a patient's national socioeconomic opportunity and their time to presentation, chemotherapy treatment, time to and type of surgical resection, or disease-free and overall survival. Prior work has shown an association between socioeconomic background and disparities in osteosarcoma treatment. It is possible that these findings will be similar to those from other hospitals and geographic areas, but based on our findings, we believe that proximity to providers, access to public transit, and regional insurance policies may help diminish these disparities. Future multicenter studies are needed to further explore the role that regional variations and the aforementioned factors may play in osteosarcoma treatment to help inform the direction of public policy. LEVEL OF EVIDENCE Level III, therapeutic study.

中文翻译：

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不同富裕程度的患者是否接受不同的小儿骨肉瘤护理？一个机构的经验。


背景 已发表的调查社会经济因素及其与骨肉瘤表现和治疗关系的报告表明，较低的社会经济地位与对化疗的反应较差和生存率较低之间存在关联。然而，这些差异背后的驱动因素尚不清楚。儿童机会指数由 diversitydatakids.org （https://www.diversitydatakids.org/） 于 2014 年开发，用于在一个专门针对儿科人群量身定制的指数中累积量化健康的社会决定因素，并按人口普查区进行组织。儿童机会指数可用于探索患者的社会经济背景与骨肉瘤表现、治疗和结果差异之间的关系。问题/目的 儿童儿童机会指数评分的差异是否与 （1） 从症状出现到骨肉瘤第一次就诊的时间，（2） 化疗的时间或手术切除的时间和类型，或 （3） 初始疾病的严重程度、转移性疾病的发展或总生存期的差异有关？方法 使用从 2006 年至 2022 年位于美国中大西洋地区的一家大型儿科三级癌症中心的机构记录中提取的数据进行了一项回顾性治疗研究。我们的主要站点位于城市环境中，拥有充足的公共交通。如果患者正在寻求第二意见或我们的机构不是骨科护理的主要点（24% [223 中的 54 人]）、电子病历不完整（4% [223 人中的 9 人]）、居住在国际国家（3% [223 人中的 7 人]）、复发后就诊（3% [223 人中的 7 人]），或在我们机构缺乏 2 年的随访（2% [223 人中的 4 人]）。 共有 113 名儿科患者 （18 岁以下的儿童） 符合纳入标准。儿童机会指数是一个综合指数，源自三个领域（教育、健康和环境以及社会和经济）和这些领域的 29 个指标，用于捕捉差异对儿童福祉的累积影响。收集全国童年机会分数并从 1 到 100 评分。每个分数代表美国 18 岁或以下儿童人口的相等比例。数字越高表示社会经济机会水平越高。然后将儿童机会指数总体得分分为代表儿童相对社会经济机会的三组：最低三分位数 < 34，中等三分位数 34 分，得分 > 66 最高三分位数。均值、范围、中位数、IQR 和百分比用于描述研究样本。对三组 （最低三分位数、中间和最高三分位数） 进行数据分析，评估就诊时间、治疗变化、疾病严重程度和总生存率的差异。应用卡方和 Fisher 精确检验来比较分类变量。Mann-Whitney U 检验比较了连续数据。进行为期 5 年的 Kaplan-Meier 生存分析，按儿童机会指数三分位数分层，以评估转移性疾病的发展和总体生存率。采用对数秩检验评估统计显著性。由于样本量小，我们无法控制潜在的混杂因素，例如种族和保险。 然而，童年机会指数数据所概括的三个领域（教育、健康和环境以及社会和经济）间接解释了与种族和保险状况相关的差异。结果较低水平的社会经济机会之间没有关联，表现为儿童机会指数三分位数在症状出现和首次就诊之间的间隔没有差异（±平均值 SD 最低三分位数 77 ± 67 天 [95% 置信区间 （CI） 60 至 94]，中间三分位数 69 ± 94 天 [95% CI 50 至 89]， 最高三分位数为 56 ± 58 天 [95% CI 41-71];p = 0.3）。同样，我们发现较低水平的社会经济机会之间没有关联，表现为儿童机会指数三分位数与从第一次就诊到第一次化疗所经过的时间（最低三分位数 19 ± 12 天 [95% CI 12 至 26]，中间 19 ± 14 天 [95% CI 11 至 26]，表示。 最高 15 ± 9.7 天 [95% CI 8.4-21];p = 0.31）、手术切除时间（最低三分位数 99 ± 35 天 [95% CI 87 至 111]、中间 88 ± 28 天 [95% CI 77 至 99]，最高 102 ± 64 天 [95% CI 86 至 118];p = 0.24），或手术切除类型（保肢与截肢：最低三分位数为 84% [25 例中的 21 例]，中三分位数为 83% [29 例中的 24 例]， 81% [59 人中的 48] 在最高的三分位数中接受了保肢手术;p = 0.52）。最后，我们发现 5 年无病生存率 （最低三分位数 27% [95% CI 7.8% 至 43%]、中 44% [95% CI 23% 至 59%] 和最高 56% [95% CI 40% 至 67%];p = 0.22）、总生存率 （最低 74% [95% CI 58% 至 95%]、中 82% [95% CI 68% 至 98%] 和最高 64% [95% CI 52% 至 78%];p = 0 没有差异。27），或就队列的生存率而言，不包括出现转移性疾病的患者（最低 84% [95% CI 68% 至 100%]，中间 91% [95% CI 80% 至 100%]，最高 68% [95% CI 55% 至 83%];p = 0.10）。结论 在我们对 113 名骨肉瘤患儿进行的单中心回顾性研究中，我们没有发现患者的国家社会经济机会与其就诊时间、化疗治疗、手术切除的时间和类型、无病生存期和总生存期之间存在关联。先前的工作表明，社会经济背景与骨肉瘤治疗的差异之间存在关联。这些发现可能与其他医院和地理区域的发现相似，但根据我们的发现，我们认为靠近提供者、使用公共交通和区域保险政策可能有助于缩小这些差异。未来的多中心研究需要进一步探索地区差异和上述因素在骨肉瘤治疗中可能发挥的作用，以帮助为公共政策的方向提供信息。证据级别 III 级，治疗研究。