# Geographic Disparities in Survival After Surgery for Metastatic Bone Disease: A Retrospective Analysis from a German Sarcoma Centre

## TL;DR

This study found that patients from villages and large cities in Germany had worse survival after surgery for bone cancer compared to those from small or medium towns.

## Contribution

The study identifies geographic disparities in cancer survival within a universal healthcare system using German data.

## Key findings

- Median postoperative survival was 22 months.
- Residential area size was independently associated with survival in multivariate analysis.
- Patients from villages and large cities had poorer survival than those from small or medium-sized towns.

## Abstract

Metastatic bone disease is an important challenge in orthopaedic oncology, as improved cancer survival leads to more patients requiring surgery for skeletal stabilisation. Prognostic factors such as tumour type or pathological fractures are well known. Still, the influence of socio-economic determinants is less clear and has mainly been studied in the United States. In this retrospective analysis of 243 patients treated surgically for metastatic bone disease at a German sarcoma centre, we examined the relationship between socio-economic characteristics and postoperative survival. Socio-economic data were derived from patients’ place of residence and linked to national census indicators. While several variables showed associations in univariate analysis, only the size of the residential population remained significant in multivariate analysis. Patients from villages and large cities had worse survival compared with those from small or medium-sized towns. These findings suggest regional disparities and highlight the need to better understand geographic inequalities in cancer care.

Background/Objectives: Metastatic bone disease (MBD) poses an increasing challenge in orthopaedic oncology due to prolonged survival. While clinical prognostic factors are well established, the role of socio-economic determinants remains unclear, particularly within universal healthcare systems. Methods: We retrospectively analysed 243 patients who underwent surgery for MBD (excluding spine) between 2005 and 2024 at a German sarcoma centre. Socio-economic indicators were derived from national databases and linked to patients’ residential districts. Survival was analysed using Kaplan–Meier estimates and Cox regression, adjusting for clinical confounders. Results: Median postoperative survival was 22 months. Several socio-economic indicators—income, education, and employment—were associated with survival in univariate analysis. In multivariate models, only residential area size remained independently significant (p = 0.047). Patients from villages (<2000 inhabitants) and large cities (>100,000) had poorer survival than those from small or medium-sized towns. This effect persisted after adjustment for tumour type, pathological fractures, and year of surgery. Conclusions: Within a universal healthcare system, residential area size was associated with survival after surgery for MBD, suggesting that regional disparities may persist despite equal formal access to care. Further studies integrating individual-level socioeconomic data are needed to identify mechanisms and guide interventions to reduce geographic inequalities.