Original Study| Volume 21, ISSUE 6, e583-e591, November 2020

Gender-based Disparities in Receipt of Care and Survival in Malignant Pleural Mesothelioma



      Despite accounting for a minority of malignant pleural mesothelioma (MPM) diagnoses, females may experience differential survival relative to males. It is unclear if there are gender-based differences in receipt of treatment or disease-related outcomes for patients with MPM. We therefore utilized the National Cancer Database (NCDB) to assess patterns-of-care and overall survival (OS) among patients with MPM by gender.

      Materials and Methods

      Patients with histologically confirmed MPM treated from 2004 to 2013 were identified from the NCDB. The association between female gender and OS was assessed using multivariable Cox proportional hazards models with propensity score matching. Patterns-of-care were assessed using multivariable logistic regression. The overall treatment effect was tested in subsets of patients by treatment strategy, histology, and clinical stage.


      A total of 18,799 patients were identified, of whom 14,728 (78%) were male and 4071 (22%) were female. Females were statistically more likely to present at a younger age, with fewer comorbidities, and with epithelioid histology. Despite these favorable prognostic features, women were less likely to receive surgery (P ≤ .001) or chemotherapy (P ≤ .001) compared with males. On multivariable analysis, female gender was associated with improved OS (hazard ratio, 0.83; 95% confidence interval, 0.80-0.86; P ≤ .001). Gender-based survival differences were seen across all stages, but only among patients with epithelioid (P ≤ .001) and not biphasic (P = .17) or sarcomatoid (P = 1.00) histology.


      Surgery and chemotherapy are disproportionately underutilized in female patients with MPM. Despite this concerning disparity, female gender is independently associated with improved survival relative to males. Further research to understand factors that lead to gender disparities in MPM is warranted.


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        • Price B.
        • Ware A.
        Time trend of mesothelioma incidence in the United States and projection of future cases: an update based on SEER data for 1973 through 2005.
        Crit Rev Toxicol. 2009; 39: 576-588
        • Curran D.
        • Sahmoud T.
        • Therasse P.
        • van Meerbeeck J.
        • Postmus P.E.
        • Giaccone G.
        Prognostic factors in patients with pleural mesothelioma: the European Organization for Research and Treatment of Cancer experience.
        J Clin Oncol. 1998; 16: 145-152
        • Flores R.M.
        • Zakowski M.
        • Venkatraman E.
        • et al.
        Prognostic factors in the treatment of malignant pleural mesothelioma at a large tertiary referral center.
        J Thorac Oncol. 2007; 2: 957-965
        • Liu B.
        • van Gerwen M.
        • Bonassi S.
        • Taioli E.
        • International Association for the Study of Lung Cancer Mesothelioma Task Force
        Epidemiology of environmental exposure and malignant mesothelioma.
        J Thorac Oncol. 2017; 12: 1031-1045
        • Taioli E.
        • Wolf A.S.
        • Camacho-Rivera M.
        • Flores R.M.
        Women with malignant pleural mesothelioma have a threefold better survival rate than men.
        Ann Thorac Surg. 2014; 98: 1020-1024
        • Wolf A.S.
        • Richards W.G.
        • Tilleman T.R.
        • et al.
        Characteristics of malignant pleural mesothelioma in women.
        Ann Thorac Surg. 2010; 90: 949-956
        • Sugarbaker D.J.
        • Wolf A.S.
        • Chirieac L.R.
        • et al.
        Clinical and pathological features of three-year survivors of malignant pleural mesothelioma following extrapleural pneumonectomy.
        Eur J Cardiothorac Surg. 2011; 40: 298-303
        • Marinaccio A.
        • Nesti M.
        • Regional Operational Centers
        Analysis of survival of mesothelioma cases in the Italian register (ReNaM).
        Eur J Cancer. 2003; 39: 1290-1295
        • Herndon J.E.
        • Green M.R.
        • Chahinian A.P.
        • Corson J.M.
        • Suzuki Y.
        • Vogelzang N.J.
        Factors predictive of survival among 337 patients with mesothelioma treated between 1984 and 1994 by the Cancer and Leukemia Group B.
        Chest. 1998; 113: 723-731
        • Antman K.
        • Shemin R.
        • Ryan L.
        • et al.
        Malignant mesothelioma: prognostic variables in a registry of 180 patients, the Dana-Farber Cancer Institute and Brigham and Women’s Hospital experience over two decades, 1965–1985.
        J Clin Oncol. 1988; 6: 147-153
        • Hillerdal G.
        Mesothelioma: cases associated with nonoccupational and low dose exposures.
        Occup Environ Med. 1999; 56: 505-513
        • Pinton G.
        • Brunelli E.
        • Murer B.
        • et al.
        Estrogen receptor-beta affects the prognosis of human malignant mesothelioma.
        Cancer Res. 2009; 69: 4598-4604
        • Milano M.T.
        • Zhang H.
        Malignant pleural mesothelioma: a population-based study of survival.
        J Thorac Oncol. 2010; 5: 1841-1848
        • American College of Surgeons
        National Cancer Database.
        (Available at:)
        • Verma V.
        • Ahern C.A.
        • Berlind C.G.
        • et al.
        National Cancer Database report on pneumonectomy versus lung-sparing surgery for malignant pleural mesothelioma.
        J Thorac Oncol. 2017; 12: 1704-1714
        • Verma V.
        • Ahern C.A.
        • Berlind C.G.
        • et al.
        Survival by histologic subtype of malignant pleural mesothelioma and the impact of surgical resection on overall survival.
        Clin Lung Cancer. 2018; 19: e901-e912
        • Austin P.C.
        An introduction to propensity score methods for reducing the effects of confounding in observational studies.
        Multivariate Behav Res. 2011; 46: 399-424
        • Austin P.C.
        Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples.
        Stat Med. 2009; 28: 3083-3107
        • Barraclough H.
        • Simms L.
        • Govindan R.
        Biostatistics primer: what a clinician ought to know: hazard ratios.
        J Thorac Oncol. 2011; 6: 978-982
        • Johansen E.L.R.
        • Lousdal M.L.
        • Skriver M.V.
        • et al.
        Predicting difference in mean survival time from reported hazard ratios for cancer patients.
        Med Decis Making. 2019; 39: 228-238
        • White I.R.
        • Royston P.
        • Wood A.M.
        Multiple imputation using chained equations: Issues and guidance for practice.
        Stat Med. 2011; 30: 377-399
        • Tsao A.S.
        • Lindwasser O.W.
        • Adjei A.A.
        • et al.
        Current and future management of malignant mesothelioma: a consensus report from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and Mesothelioma Applied Research Foundation.
        J Thorac Oncol. 2018; 13: 1655-1667
        • De Rienzo A.
        • Archer M.A.
        • Yeap B.Y.
        • et al.
        Gender-specific molecular and clinical features underlie malignant pleural mesothelioma.
        Cancer Res. 2016; 76: 319-328
        • Meyerhoff R.R.
        • Yang C.F.
        • Speicher P.J.
        • et al.
        Impact of mesothelioma histologic subtype on outcomes in the Surveillance, Epidemiology, and End Results database.
        J Surg Res. 2015; 96: 23-32
        • Mansfield A.S.
        • Symanowski J.T.
        • Peikert T.
        Systematic review of response rates of sarcomatoid malignant pleural mesotheliomas in clinical trials.
        Lung Cancer. 2014; 86: 133-136
        • Friedberg J.S.
        • Simone 2nd, C.B.
        • Culligan M.J.
        • et al.
        Extended pleurectomy-decortication-based treatment for advanced stage epithelial mesothelioma yielding a median survival of nearly three years.
        Ann Thorac Surg. 2017; 103: 912-919
        • Simone 2nd, C.B.
        • Cengel K.A.
        Photodynamic therapy for lung cancer and malignant pleural mesothelioma.
        Semin Oncol. 2014; 41: 820-830
        • Gomez D.R.
        • Rimner A.
        • Simone 2nd, C.B.
        • et al.
        The use of radiation therapy for the treatment of malignant pleural mesothelioma: expert opinion from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, the Mesothelioma Applied Research Foundation.
        J Thorac Oncol. 2019; 14: 1172-1183
        • Rose T.L.
        • Deal A.M.
        • Nielsen M.E.
        • Smith A.B.
        • Milowsky M.I.
        Sex disparities in use of chemotherapy and survival in patients with advanced bladder cancer.
        Cancer. 2016; 122: 2012-2020
        • Verma V.
        • Wegner R.E.
        • Brooks E.D.
        • et al.
        Chemotherapy versus supportive care for unresected malignant pleural mesothelioma.
        Clin Lung Cancer. 2019; 20: 263-269
        • Verma V.
        • Ahern C.A.
        • Berlind C.G.
        • et al.
        Facility volume and postoperative outcomes for malignant pleural mesothelioma: a National Cancer Data Base analysis.
        Lung Cancer. 2018; 120: 7-13
        • Verma V.
        • Ahern C.A.
        • Berlind C.G.
        • et al.
        Treatment of malignant pleural mesothelioma with chemotherapy preceding versus following surgical resection.
        J Thorac Cardiovasc Surg. 2019; 157: 758-766
        • Verma V.
        • Wegner R.E.
        • Ludmir E.B.
        • et al.
        Management of malignant pleural mesothelioma in the elderly population.
        Ann Surg Oncol. 2019; 26: 2357-2366
        • Verma V.
        • Sleightholm R.L.
        • Rusthoven C.G.
        • et al.
        Malignant peritoneal mesothelioma: national practice patterns, outcomes, and predictors of survival.
        Ann Surg Oncol. 2018; 25: 2018-2026
        • Verma V.
        • Wegner R.E.
        • Adeberg S.
        • et al.
        Management of clinically lymph node-positive malignant pleural mesothelioma.
        Semin Thorac Cardiovasc Surg. 2019; (Online ahead of print)