title: Making a case for the socioeconomic determinacy of survival in osteosarcoma.
abstract: BACKGROUND
  The literature on osteosarcoma survival generally focuses on tumor and treatment variables, although it is unclear whether and how ethnic and socioeconomic factors might influence survival.
  
  
  OBJECTIVE
  We therefore investigated the relative contribution of socioeconomic influences together with more traditional tumor-specific factors on osteosarcoma survival.
  
  
  METHODS
  We performed survival analyses on two national databases in two countries. Using multivariable analyses, we compared these with corresponding institution-specific survival to determine if socioeconomic factors might impact osteosarcoma survival.
  
  
  RESULTS
  East Asian descent, state-specific treatment, female sex, treatment in the 1990s, low-grade disease, intracompartmental disease, small size, wide resections as opposed to forequarter or hindquarter amputations, and single primaries were good prognostic factors. Survival was better in the more affluent states. Males were affected at an older age than females. Blacks tended to have larger tumors, although their overall survival was similar to whites. East Asians were more likely to be treated in the 1990s with wide resections for smaller tumors and were located around states associated with good treatment. East Asians in Singapore and the United States had the same survival. Survival in East Asians in Singapore was similar to that of other races. The provision of health care for osteosarcoma varies greatly across the United States but is uniform in the socialized medical system in Singapore. Hence, the observed differences in the United States were likely the result of socioeconomic factors.
  
  
  CONCLUSIONS
  Our analysis suggests ethnic and economic bias may influence survival in osteosarcoma and should receive greater attention in the collective literature on survival analyses.
  
  
  METHODS
  Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedics, National University of Singapore Yong Loo Lin School of Medicine, Level 11, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore. dosssn@nus.edu.sg
authors.forename: Saminathan S
authors.initials: SS
authors.lastname: Nathan
authors.forename: John H
authors.initials: JH
authors.lastname: Healey
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000671:Amputation, Surgical / Q000401:mortality; D001859:Bone Neoplasms / Q000191:economics / Q000208:ethnology / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007182:Income; D007223:Infant; D053208:Kaplan-Meier Estimate; D008297:Male; D015999:Multivariate Analysis; D012516:Osteosarcoma / Q000191:economics / Q000208:ethnology / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D010027:Osteotomy / Q000401:mortality; D016016:Proportional Hazards Models; D044469:Racial Groups; D012189:Retrospective Studies; D018426:SEER Program; D012737:Sex Factors; D012846:Singapore; D012959:Socioeconomic Factors; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D055815:Young Adult