Pituitary Adenoma Surgery and the Pursuit of Health Equity

Pituitary adenomas make up approximately 10% of primary brain tumors, and about 10,000 cases are diagnosed each year in the United States. Though relatively common in the field of neurosurgery, there is very little information on the impact healthcare disparities have on the care patients receive for these benign -- but not harmless -- tumors.

Researchers with Cleveland Clinic in Florida conducted a systematic literature review to examine various aspects of race, socioeconomic status (SES), age, and gender disparities in the treatment of pituitary adenomas in hopes of uncovering their influence on surgical outcomes. Their findings were published in the November 2023 issue of Neurosurgical Focus.

First-of-its-kind study

“Understanding the significance of diversity, equity, and inclusion factors is imperative in our pursuit of optimizing patient care,” says Hamid Borghei-Razavi, MD, Director of the Minimally Invasive Cranial and Pituitary Surgery Program at Cleveland Clinic Weston Hospital and the study’s senior author. “We believe this is the first comprehensive examination of its kind to look at healthcare disparities in patients with pituitary adenomas.”

The researchers identified 21 U.S.-based studies in their literature review encompassing four electronic scientific databases: MEDLINE (PubMed), Web of Science, Scopus, and Embase. They initially yielded a total of 381,643 patients, but after removal of studies with temporal overlap, their findings included 134,832 patients. The mean ± SD age was 51.52 ± 0.41 years, and 46.63% of patients were male, based on available data.

Key findings

“As we anticipated, our review identified healthcare disparities linked to race, income, insurance, age, and gender,” says the study’s lead author Mohammadmahdi Sabahi, MD, MPH, a postdoctoral research fellow in the Department of Neurosurgery at Cleveland Clinic Weston Hospital. “They were observed in terms of surgery recommendations, postoperative course and outcomes, as well as admission and hospital charges.”

The following are some of the researchers’ key findings.

• Black patients were more likely to be recommended against surgery and less likely to undergo endoscopic surgery, while Asian or Pacific Islander patients were more likely to be recommended for surgery.
• Postoperative course and outcome showed mixed results, with some studies reporting higher rates of transient diabetes insipidus and stroke in racial minority populations.
• Private hospitals admitted more White patients, and certain racial groups had reduced access to high-volume centers.
• Patients with government insurance or without insurance were more likely to be recommended active surveillance instead of definitive treatment. These SES factors also were associated with higher mortality rates.
• Meanwhile, high SES was associated with a higher likelihood of receiving surgical treatment, better treatment outcomes, and better access to high-volume centers.
• Patients with higher income had longer follow-up durations and lower likelihood of recurrence, whereas low SES contributed to poor medication adherence and inadequate procedure follow-up.
• Older patients and females were less likely to be recommended for surgical treatment. Age and gender did not consistently impact postoperative course and treatment outcomes, with varying results across studies.
• Younger age and female gender, however, were associated with better survival in patients with invasive adenomas, while older age and male gender were associated with increased mortality rates.

A lack of trust?

In the discussion of their findings, the researchers noted that bias can influence clinical and surgical decision-making, which may contribute to inequitable access to appropriate treatment options for pituitary adenomas. “It’s imperative as physicians that we acknowledge our personal biases and the role they play in how we deliver care,” says Dr. Sabahi.

The researchers also identify patient trust as a factor that should be taken into account when trying to address healthcare disparities.

“Patient trust, or the lack thereof, in the healthcare system could affect healthcare-seeking behaviors and treatment plan adherence,” suggests Dr. Sabahi. “The trust patients place in us can be influenced by perceptions of how they are treated on the basis of their race, age, gender and other factors. It can also be shaped by past experiences with insufficient access, lack of representation, and perceived differences in quality of care.”

Promoting diversity

The Minimally Invasive Cranial and Pituitary Surgery Program at Weston Hospital is part of Cleveland Clinic’s Brain Tumor Center in Florida. It is a high-volume referral center that draws patients from across the Florida region as well as international patients from Latin America and the Caribbean.

“We care for a diverse patient population and conduct outreach into local communities and abroad where access to our level of tertiary care is limited,” says Dr. Borghei-Razavi. “We believe embracing diversity and fostering culturally competent and sensitive care is essential to achieving Cleveland Clinic’s mission.”

Dr. Borghei-Razavi also points to the Weston-based clinical and research fellowships in skull base surgery as another way Cleveland Clinic promotes diversity, equity and inclusion in the field. “GME trainees are welcomed from diverse backgrounds, and our faculty are encouraged to look for and address unconscious bias throughout the instructional process.”.

For more information, visit Cleveland Clinic Florida ConsultQD. Subscribe to the Florida Physician Newsletter.
Additionally, follow us on X (formerly Twitter), Facebook, and LinkedIn.