Outcomes of localized malignant pleural mesothelioma (MPM) remain poor despite multimodality therapy. It is unclear what role disparities in access to care or patient’s socio-economic status (SES) play in disease-related outcomes for operable MPM. We utilized the National Cancer Database (NCDB) to assess patterns-of-care and overall survival (OS) among patients with MPM by treatment access and patient SES characteristics. Patients with stage I-IIIA MPM treated from 2004 to 2017 were identified from the NCDB. Descriptive statistics were used to compare patients who underwent chemotherapy alone with those with multimodality treatment with surgery. Propensity score analysis was used to adjust treatment groups. Multivariable logistic regression model was used to evaluate the association between patient characteristics, access to care (SES and facility-related variables) on overall survival (OS). A total of 2804 patients were identified with a median age of 65 years. Of the patients that had surgery (n=1402), the majority were men (70%), of White Race (83.1%), Stage I-II (86.7%), and epithelioid mesothelioma (58.9%). Compared to patients that had no surgery, patients who received surgery as part of their treatment were travelling a greater distance for treatment (mean 16.10 miles vs 14.40 (p<0.001) and received treatment at an academic center (57.3% vs 49.2% (p<0.001) or higher volume facility. Very few patients receiving surgical treatment lived in rural areas (1.6%). Of patients that had surgical therapy, most had private insurance (47.7%), Medicare (44.6%) and only 3.4% had Medicaid or no insurance (2.3%). There was no difference in receipt of surgical treatment by educational attainment. On a multivariate analysis adjusting for patient and tumor characteristics, as well as SES and facility-related variables, there was no significant difference in OS by race, insurance, educational attainment, Charlson-Deyo Comorbidity Index, facility type and volume. Factors predictive of poor OS included advanced age (HR 1.02, CI: 1.02-1.03) and male gender (HR 1.43, CI: 1.29-1.58). Surgical treatment in addition to systemic chemotherapy alone (HR 0.61 CI: 0.55-0.67) or systemic therapy and radiotherapy (HR 0.73, CI: 0.62-0.86) were independently associated with improved OS, as well as prolonged chemotherapy treatment (HR 0.998 CI: 0.997-0.999), all P<.001.Interestingly, patients in the 3rd quartile of income ($50,354-63,332) had better survival than the highest quartile of income (>=$63,333), with 17% reduction of overall mortality risk (HR 0.83, 95%CI: 0.74 - 0.92; p= 0.001 after adjustment for patient, tumor, and facility-related variables). But no significant SES effect for the 2 lowest income quartiles (< $40,227 and $40,227-50,353). Among patients with operable MPM, there is significant variability in access to care (distance to facility, facility type and volume). In a multivariate analysis, receipt of chemotherapy or multimodality treatment (chemotherapy and radiotherapy) predicted better outcomes despite patient’s race, SES and tumor characteristics. We identified improvement in survival for those in the 3rd quartile of income when compared to those with lower income. Addressing disparities in access to surgery and multimodality therapy can help ensure equity of care for patients with MPM.