Race and Socioeconomic Status in the Management of Vestibular Schwannomas: Interactions and Trends Over the Past 20 Years

Introduction: Vestibular schwannomas (VS) are benign tumors arising in the vestibulocochlear nerve, managed with stereotactic radiosurgery (SRS), surgical resection, fractionated radiotherapy, or observation. Previous research found racial disparities in surgical intervention for primary brain tumors, including VS, controlling for insurance status. This paper explores interactions between income/socioeconomic status (SES) and race in influencing VS management and evolution over time.

Methods: Using the national Surveillance, Epidemiology, and End Results (SEER) database, this retrospective analysis collated demographic, clinical, and treatment data on 23,488 VS cases from 2004 to 2021. Categorical data was analyzed with chi-square and Cramer’s V to calculate effect size phi. Relationships between tumor size, SES, and race were analyzed with logistic regression. Analyses were completed for the whole cohort, then repeated for the 2016–2021 cohort only, to assess trends.

Results: Black patients across socioeconomic statuses are less likely to have VS surgery than non-Black patients (p < 0.001) ([Fig. 1]). For other races, top quintile patients tend to have the lowest rates of surgical intervention within their respective race categories (Asian: 35.7%, Hispanic: 34.8%, white: 31.1%). This trend is not observed in Black patients, where all except for the middle quintile have similar surgical rates in the 2004–2021 cohort. Black patients of all quintiles are less likely to undergo surgery than patients of any SES in other race categories, a trend that persisted in the 2016–2021 cohort ([Fig. 2]). Chi-square analysis supported a significant association of SES with treatment modality for Hispanic, Asian, and white populations (p < 0.001 for all) but only approaching significance in Black patients (p = 0.095). This trend persisted in the 2016–2021 cohort ([Fig. 2]). The effect size of race / SES on treatment was phi = 0.047/0.050, respectively, but phi = 0.078/0.060 in the 2016–2021 cohort. Logistic regression for treatment modality included SES and race as factors and tumor size as a covariate ([Fig. 2]). For the whole cohort and when analysis was restricted to 2016–2021, race, SES, and tumor size were all significant predictors of treatment (all p < 0.001).

Discussion: When apparent racial disparities are discovered, the question of socioeconomic status as a confounding factor often arises. However, our results support that decreased surgical intervention in VS for Black patients is not solely attributable to SES. SES was found to have a significant impact on treatment for all except Black patients. The effect sizes for race and SES on treatment in the overall cohort are similar. For the 2016–2021 cohort, the effect size of race is much greater than that of SES, supporting a relatively stronger role for race compared with SES in influencing VS management. This trend may be partly explained by the 2010 passage of the Affordable Care Act. Race remains a determinant of treatment modality in the 2016–2021 cohort despite increased awareness of racial health disparities accelerated by the COVID-19 pandemic.

Publication History

Article published online:
07 February 2025