Underuse of Esophagectomy as Treatment for Resectable Esophageal Cancer

Paulson, Emily Carter; Ra, Jin; Armstrong, Katrina; Wirtalla, Christopher; Spitz, Francis R.; Kelz, Rachel R.

doi:10.1001/archsurg.143.12.1198

Cited by 75 publications

(70 citation statements)

References 40 publications

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“…Separate analyses of the SEER and SEER-Medicare databases, have shown that surgery is underutilized among black patients with potentially resectable esophageal cancer. [5–10] The current study confirms that resection rates are lower among non-white patients. It is plausible that disparities in resection rates are more pronounced in black and hispanic patients because of the higher proportion of SCC and therefore mid-esophageal tumors among these groups.…”

Section: Discussionsupporting

confidence: 80%

“…[7–9] For many cancer types, race and ethnicity are significant predictors of non-operative management among patients with potentially resectable tumors. [7,10–12] Lower socioeconomic status, higher burden of comorbid conditions, and differential access to surgical specialists have been associated with failure to undergo cancer-directed surgery. [13] However, accounting for patient level factors and access-related issues have failed to fully explain the underuse of surgical resection and the excess mortality observed in non-white patients with esophageal cancer.…”

Section: Introductionmentioning

confidence: 99%

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Racial Disparities in Esophageal Cancer Outcomes

et al. 2012

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Introduction 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. Methods 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 (SCC) 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. Results 6,737 patient files (84% white, 10% black, 6% hispanic) were analyzed. Black and hispanic patients were more likely than whites to have SCC (86% vs. 41% vs. 26%, respectively; p<0.001) and lesions in the mid-esophagus (58% vs. 38% vs. 26%, respectively; p<0.001). Blacks and hispanics were less likely to undergo esophagectomy (adjusted OR 0.49, 95%CI=0.39–0.60 and 0.72, 95%CI=0.57–0.90). We noted significant variations in esophagectomy rates among patients with mid-esophageal 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 (HR 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. Conclusion 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 non-white patients and develop interventions, especially for mid-esophageal cancers.

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Section: Discussionsupporting

confidence: 80%

Section: Introductionmentioning

confidence: 99%

Racial Disparities in Esophageal Cancer Outcomes

et al. 2012

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“…Esophageal cancer is highly lethal with 11,650 (88.7%) estimated deaths among men and 2,850 (81.2%) among women. 2 Taken together with previous population studies, [3][4][5][6][7][8][9] the latter suggests a survival benefit for women when compared with men. The prevalence of the two main histologic subtypes-adenocarcinoma and squamous cell carcinoma-differs depending on geographic location.…”

Section: Introductionsupporting

confidence: 55%

Influence of Sex on the Survival of Patients With Esophageal Cancer

Bohanes

Yang

Chhibar

et al. 2012

JCO

119

115

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A B S T R A C T PurposeThe prognostic value of sex for esophageal cancer survival is currently unclear, and growing data suggest that hormonal influences may account for incidence disparities between men and women. Therefore, moving from the hypothesis that hormones could affect the prognosis of patients with esophageal cancer, we investigated the primary hypothesis that sex is associated with survival and the secondary hypotheses that the relationship between sex and survival depends, at least in part, on age, histology, and race/ethnicity. Patients and MethodsBy using the SEER databases from 1973 to 2007, we identified 13,603 patients (34%) with metastatic esophageal cancer (MEC) and 26,848 patients (66%) with locoregional esophageal cancer (LEC). Cox proportional hazards model for competing risks were used for analyses. ResultsIn the multivariate analysis, women had longer esophageal cancer-specific survival (ECSS) than men in both MEC (hazard ratio [HR], 0.949; 95% CI, 0.905 to 0.995; P ϭ .029) and LEC (HR, 0.920; 95% CI, 0.886 to 0.955; P Ͻ .001) cohorts. When age and histology were accounted for, there was no difference for ECSS between men and women with adenocarcinoma. In contrast, women younger than age 55 years (HR, 0.896; 95% CI, 0.792 to 1.014; P ϭ .081) and those age 55 years or older (HR, 0.905; 95% CI, 0.862 to 0.950; P Ͻ .001) with squamous cell LEC had longer ECSS than men. In the squamous cell MEC cohort, only women younger than age 55 years had longer ECSS (HR, 0.823; 95% CI, 0.708 to 0.957; P ϭ .011) than men. ConclusionSex is an independent prognostic factor for patients with LEC or MEC. As secondary hypotheses, in comparison with men, women age 55 years or older with squamous cell LEC and women younger than age 55 years with squamous cell MEC have a significantly better outcome. These last two findings need further validation.

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“…11 In separate studies of the SEER-Medicare database, Paulson et al and Steyerberg et al demonstrated that black patients with early stage esophageal cancer were substantially less likely to undergo surgery compared to whites. 24,25 Mathur and colleagues documented similar findings in patients with early stage liver cancer. 6 …”

Section: Discussionmentioning

confidence: 71%

Racial Disparities in Surgical Resection and Survival among Elderly Patients with Poor Prognosis Cancer

Revels

Banerjee

Yin

et al. 2013

Journal of the American College of Surgeons

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Background Reports indicate that blacks have lower survival following the diagnosis of a poor prognosis cancer, compared with whites. We explored the extent to which this disparity is attributable to the underuse of surgery. Study Design Using the SEER-Medicare database we identified 57,364 patients, ages ≥65, with a new diagnosis of non-metastatic liver, lung, pancreatic and esophageal cancer, from 2000-2005. We evaluated racial differences in resection rates after adjustment for patient, tumor and hospital characteristics, using hierarchical logistic regression. Cox proportional hazards regression was used to assess racial differences in survival, after adjusting for patient, tumor and hospital characteristics, and receipt of surgery. Results Compared with whites, blacks were less likely to undergo surgery for liver (adjusted OR [aOR], 0.49, 95%CI 0.29-0.83), lung (aOR 0.62 95%CI 0.56-0.69), pancreas (aOR 0.53, 95%CI 0.41-0.70) and esophagus cancers (aOR 0.64, 95%CI 0.42-0.99). Hospitals varied in their surgery rates among patients with potentially resectable disease. However, resection rates were consistently lower for blacks, regardless of the resection rate of the treating hospital. Although there were no racial differences in overall survival with liver and esophageal cancer, blacks experienced poorer survival for lung (adjusted HR [aHR]1.05, 95%CI 1.00-1.10) and pancreas cancer (aHR 1.15, 95%CI 1.03-1.30). In both instances, there were no residual racial disparities in overall survival after further adjusting for use of surgery. Conclusions Blacks are less likely to undergo surgery following the diagnosis of a poor prognosis cancer. Our findings suggest that surgery is an important predictor of overall mortality, and that efforts to reduce racial disparities will require stakeholders to gain a better understanding of why elderly blacks are less likely to get to the operating room.

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Underuse of Esophagectomy as Treatment for Resectable Esophageal Cancer

Cited by 75 publications

References 40 publications

Racial Disparities in Esophageal Cancer Outcomes

Racial Disparities in Esophageal Cancer Outcomes

Influence of Sex on the Survival of Patients With Esophageal Cancer

Racial Disparities in Surgical Resection and Survival among Elderly Patients with Poor Prognosis Cancer

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