Abstract
The incidence of esophageal adenocarcinoma (EAC) is increasing worldwide and has overtaken squamous histology in occurrence. We studied the impact of socioeconomic status (SES) on EAC stage at diagnosis, receipt of treatment, and survival. A population-based retrospective cohort study was conducted using Ontario Cancer Registry-linked administrative health data. Multinomial logistic regression was used to examine the association between SES (income quintile) and stage at EAC diagnosis and EAC treatment. Survival times following EAC diagnosis were estimated using Kaplan-Meier method. Cox proportional-hazards regression analysis was used to examine the association between SES and EAC survival. Between 2003–2012, 2,125 EAC cases were diagnosed. Median survival for the lowest-SES group was 10.9 months compared to 11.6 months for the highest-SES group; the 5-year survival was 9.8% vs. 15.0%. Compared to individuals in the highest-SES group, individuals in the lowest-SES category experienced no significant difference in EAC treatment (91.6% vs. 93.3%, P = 0.314) and deaths (78.9% vs. 75.6%, P = 0.727). After controlling for covariates, no significant associations were found between SES and cancer stage at diagnosis and EAC treatment. Additionally, after controlling for age, gender, urban/rural residence, birth country, health region, aggregated diagnosis groups, cancer stage, treatment, and year of diagnosis, no significant association was found between SES and EAC survival. Moreover, increased mortality risk was observed among those with older age (P = 0.001), advanced-stage of EAC at diagnosis (P < 0.001), and those receiving chemotherapy alone, radiotherapy alone, or surgery plus chemotherapy (P < 0.001). Adjusted proportional-hazards model findings suggest that there is no association between SES and EAC survival. While the unadjusted model suggests reduced survival among individuals in lower income quintiles, this is no longer significant after adjusting for any covariate. Additionally, there is an apparent association between SES and survival when considering only those individuals diagnosed with stage 0-III EAC. These analyses suggest that the observed direct relationship between SES and survival is explained by patient-level factors including receipt of treatment, something that is potentially modifiable.
Highlights
Esophageal adenocarcinoma (EAC) is predominantly a disease of the distal esophagus and gastroesophageal junction
A flow chart of the study population can be found in S1 Fig. Overall sociodemographic and clinical characteristics of patients diagnosed with EAC and by year of EAC diagnosis are summarized in S3 Table
There was an increase in EAC diagnosis from 16.0% during the period 1993–1997 to 35.1% during 2008–2012
Summary
Esophageal adenocarcinoma (EAC) is predominantly a disease of the distal esophagus and gastroesophageal junction. EAC incidence has greatly increased over the past three decades, gaining global relevance as a clinically important cancer [1–4]. Despite improvements in the care of patients with EAC, overall mortality remains high, with a 5-year relative survival of 14% between 2006 and 2008 [15]. Poor mortality is thought to occur because most patients with EAC present with advanced-stage disease, after symptoms of dysphagia are already present, and are not eligible for highly effective and usually curative endoscopic therapies [6]. Socioeconomic status (SES) may affect how individuals with Barrett’s esophagus or EAC follow cancer screening and treatment recommendations. Lower SES was found to be associated with cancer stage at diagnosis, longer health care delay, and varying receipt of treatment for esophageal cancer [16]
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