Socioeconomic disparities in reception of limb-sparing surgery versus amputation for lower extremity sarcoma

Kim, Dylan K., et al. “Socioeconomic Disparities in Reception of Limb-Sparing Surgery versus Amputation for Lower Extremity Sarcoma.” Journal of Plastic, Reconstructive & Aesthetic Surgery, vol. 99, Dec. 2024, pp. 436–444, https://doi.org/10.1016/j.bjps.2024.10.005.

Read the paper here.

Background

Sarcomas are rare cancers starting in connective tissues like muscle, fat, nerves, and bone. They begin in "mesenchymal cells," which are embryonic cells that can turn into many different body parts. About 30% of soft tissue sarcomas are found in the legs. Historically, the main treatment was amputation (removing the leg), but now doctors prefer limb-sparing surgery (limb salvage) whenever possible.The goal of limb-sparing surgery is to remove the tumor plus a "margin" of healthy tissue to ensure no cancer is left behind. Surgeons then rebuild the leg using metal prostheses or bone grafts. This surgery provides a better quality of life and makes patients feel more independent. Despite medical standards, factors like income, insurance, and location may impact care. This study uses the SEER database (2007–2021) to see how race, income, and location act as barriers to care.

Methods

Scientists used the SEER database to study 6,465 adults diagnosed with leg sarcomas between 2007 and 2021. SEER covers about 26.5% of the U.S. population in various regions, including the Western, Northeastern, Southern, and Midwestern U.S.. Researchers used ICD-O-3 codes (like C40.2 and C49.2) to identify specific tumors. They only included patients who had either limb-sparing surgery or amputation. They looked at demographics (race and ethnicity), socioeconomics (household income and location), and oncology characteristics (cancer stage, additional therapies, tumor size). They used multivariate binary logistic regression to look at all factors at once and odds ratios (OR) to compare risks. Survival was measured using Kaplan-Meier graphs and a "Cox model". 

Results

The researchers started with 21,836 diagnoses and narrowed them down to a final group of 6,465 patients. The average age was 58.7 years. Most were Non-Hispanic White (65%), lived in big cities (64%), and earned between $75,000 and $99,999 (41%).

About 91% of patients had limb-sparing surgery, while 9.1% had an amputation. Amputation rates fell from 11.3% in 2007 to 9.0% by 2021. However, risk was not equal for everyone. Even when accounting for cancer stage and size, socioeconomic factors mattered.

Conclusion

Disparities exist in how leg sarcomas are treated in the U.S.. Minority race and living in rural areas are major barriers to saving a limb. Rural patients may lack access to the specialized plastic surgeons and hospital equipment needed to rebuild a leg. Because limb-sparing surgery is linked to better 10-year survival, access to this care is critical for long-term health. To fix this, we need health reforms like expanding Medicaid and helping rural patients travel to major cancer centers. Everyone deserves high-quality care regardless of their background or zip code.

Future Directions