Racial Disparities in Esophageal Cancer Outcomes

Abstract

Racial disparities in outcomes have been documented among patients with esophageal cancer. The purpose of this study is to identify mechanisms for ethnicity/race-related differences in the use of cancer-directed surgery and mortality. Data from the Surveillance, Epidemiology and End Results (SEER) program were used to evaluate non-Hispanic black, non-Hispanic white and Hispanic patients diagnosed with non-metastatic esophageal cancer (squamous cell carcinoma or adenocarcinoma) from 2003-2008. Age, marital status, stage, histology and location were examined as predictors of receipt of surgery and mortality in multivariate analyses. A total of 6,737 patient files (84% white, 10% black, 6% Hispanic) were analyzed. Black and Hispanic patients were more likely than whites to have squamous cell carcinoma (86 vs. 41 vs. 26%, respectively; p<0.001) and lesions in the midesophagus (58 vs. 38 vs. 26%, respectively; p<0.001). Blacks and Hispanics were less likely to undergo esophagectomy (adjusted odds ratio 0.48, 95% confidence interval (CI) 0.39-0.60 and 0.71, 95% CI 0.56-0.90]. We noted significant variations in esophagectomy rates among patients with midesophageal cancers; 15% of blacks underwent esophagectomy compared to 22% of Hispanics and 29% of whites (p<0.001). Black and Hispanic patients had a higher unadjusted risk of mortality (hazard ratio 1.38, 95% CI 1.25-1.52 and 1.20, 95% CI 1.05-1.37). However, differences in mortality were no longer significant after adjusting for receipt of surgery. Disparities in esophageal cancer outcomes are associated with the lower use of cancer-directed surgery. To decrease disparities in mortality it will be necessary to understand and target underlying causes of lower surgery rates in nonwhite patients and develop interventions, especially for midesophageal cancers.