Racial Disparities in Rates of Surgery for Esophageal Cancer: a Study from the National Cancer Database

Summary Esophageal cancer is one of the most common cancer killers in our country. The effects of racial disparities on care for esophageal cancer patients are incompletely understood. Using the National Cancer Database, we investigated racial disparities in treatment and outcome of esophageal cancer patients. The National Cancer Database was queried from 2004 to 2017. Logistic regression and survival analysis were used to determine racial differences in access, treatment and outcome. A total of 127,098 patients were included. All minority groups were more likely to be diagnosed at advanced stages versus Caucasians after adjusting for covariates (African American OR—1.64 [95% confidence interval 1.53—1.76], Hispanic OR—1.19 [1.08—1.32], Asian OR—1.78 [1.55—2.06]). After adjustment, all minorities were less likely at every stage to receive surgery. Despite these disparities, Hispanics and Asians had improved survival compared with Caucasians. African Americans had worse survival. Racial disparities for receiving surgery were present in both academic and community institutions, and at high-volume and low-volume institutions. Surgery partially mediated the survival difference between African Americans and Caucasians (HR—1.13 [1.10–1.16] and HR—1.04 [1.02–1.07], without and with adjustment of surgery).There are racial disparities in the treatment of esophageal cancer. Despite these disparities, Hispanics and Asians have improved overall survival versus Caucasians. African Americans have the worst overall survival. Racial disparities likely affect outcome in esophageal cancer. But other factors, such as epigenetics and tumor biology, may correlate more strongly with outcome for patients with esophageal cancer.

Download Full-text

Racial disparities in patients with unresectable stage III/IV esophageal cancer at time of diagnosis: A National Cancer Database Analysis.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e16589 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e16589-e16589

Author(s):

Meena Sadaps ◽

Neal Mehta ◽

Ran Zhao ◽

Wei Wei ◽

Amit Bhatt ◽

...

Keyword(s):

Esophageal Cancer ◽

African American ◽

Native American ◽

African Americans ◽

Racial Disparities ◽

Clinical Outcomes ◽

Locally Advanced ◽

Stage Iii ◽

National Cancer Database ◽

Unresectable Stage

e16589 Background: Significant racial disparities exist in the patterns of care and clinical outcomes for patients with early stage, non-metastatic esophageal cancer but data in advanced esophageal cancer are lacking. In this study, we aim to evaluate racial disparities in patients with locally advanced/metastatic, unresectable esophageal cancers. Methods: We identified patients in the National Cancer Database with esophageal cancer, from 2004 to 2016, with unresectable stage III/IV disease at time of diagnosis. We compared overall survival (OS) between different racial groups as well as other demographic and socioeconomic factors that may have contributed to this disparity. Secondary factors that were studied included age, sex, education, histology, and location of tumor. Results: 49,139 patients were included in this analysis. Median age was 64.5 years and 39,314 (80.0%) were male. 16,723 (34.0%) patients had stage III disease and 32,416 (66.0%) patients had stage IV disease. 16,208 patients (33.0%) had squamous cell carcinoma and 32,931 (67.0%) had adenocarcinoma. Patients were stratified into one of the following six categories for race: Caucasian (40,139; 81.7%), African American (5,571; 11.3%), Asian (907; 1.8%), Hispanic/Latino (1,793; 3.6%), Native American (145; 0.3%), and other (167; 0.3%). African Americans had worse median OS (Table) than Asians (p = 0.000), Hispanic/Latinos (p = 0.000), and Caucasians (p = 0.001) when analyzed in a pairwise comparison using log-rank testing. Within the African American subset, older age ( > 70 years) (p = 0.00), male gender (p = 0.00), and tumor location in the mid (p = 0.02) or upper third (p = 0.00) of the esophagus were associated with worse outcomes using Cox’s multivariate regression model. Conclusions: Racial disparities persist even in unresectable stage III/IV esophageal cancer patients with African Americans noted to have worse clinical outcomes as compared to most other races including Caucasian, Asian, and Hispanic/Latino patients. Further research is warranted to determine the cause for this disparity and to implement the necessary changes to improve outcomes for these patients. [Table: see text]

Download Full-text

518 – Racial Disparities in Rates of Surgery for Esophageal Cancer: A Study from the National Cancer Database

Gastroenterology ◽

10.1016/s0016-5085(19)37048-9 ◽

2019 ◽

Vol 156 (6) ◽

pp. S-103

Author(s):

Samantha L. Savitch ◽

Walter Scott ◽

Scott W. Cowan ◽

James Posey ◽

Edith P. Mitchell ◽

...

Keyword(s):

Esophageal Cancer ◽

Racial Disparities ◽

National Cancer Database

Download Full-text

Clinical fate of T0N1 esophageal cancer: results from the National Cancer Database

Journal of Gastrointestinal Oncology ◽

10.21037/jgo.2018.08.08 ◽

2018 ◽

Vol 9 (5) ◽

pp. 880-886 ◽

Cited By ~ 2

Author(s):

Caitlin Takahashi ◽

Ravi Shridhar ◽

Jamie Huston ◽

Kenneth Meredith

Keyword(s):

Esophageal Cancer ◽

National Cancer Database

Download Full-text

Abstract PR09: Racial disparities in health insurance status of U.S. adults with hematologic malignancies in states with and without Medicaid expansion: Analyses from the National Cancer Database, 2007-2016

10.1158/1538-7755.disp19-pr09 ◽

2020 ◽

Author(s):

Gregory S. Calip ◽

Naomi Y Ko ◽

Karen I. Sweiss ◽

Pritesh R. Patel ◽

Brian C.-H. Chiu

Keyword(s):

Health Insurance ◽

Racial Disparities ◽

Hematologic Malignancies ◽

Insurance Status ◽

National Cancer Database ◽

Medicaid Expansion ◽

Health Insurance Status ◽

Racial Disparities In Health

Download Full-text

Lymph Node Harvest as a Measure of Quality and Effect on Overall Survival in Esophageal Cancer: A National Cancer Database Assessment

The American Surgeon ◽

10.1177/000313481908500229 ◽

2019 ◽

Vol 85 (2) ◽

pp. 201-205 ◽

Cited By ~ 1

Author(s):

Mark J. Dudash ◽

Sasha Slipak ◽

James Dove ◽

Marie Hunsinger ◽

Jeffrey Wild ◽

...

Keyword(s):

Overall Survival ◽

Esophageal Cancer ◽

Lymph Node ◽

Private Insurance ◽

High Volume ◽

Academic Programs ◽

Preoperative Radiation ◽

National Cancer Database ◽

Cure Rate ◽

Extensive Lymphadenectomy

Surgical therapy for esophageal cancer is the cornerstone of treatment, and the highest quality operation should lead to the highest cure rate. Evaluated lymph node (ELN) count is one quality measure that has been championed. The objective of this study was to explore ELN in esophagectomy, examine predictors of harvesting ≥12 nodes, and determine whether higher ELN improves overall survival (OS). ELN was examined in patients with resected esophageal cancer using the National Cancer Database from 2004 to 2013. In this study, 41,746 patients met the inclusion criteria. Fifty-two per cent of patients had 12 or more nodes harvested. Academic programs were most likely to harvest ≥12 nodes (58% of cases) compared with other programs (43–56% of cases). Seventy per cent of cases with ≥12 nodes harvested were performed at high-volume centers. Preoperative radiation or preoperative chemoradiation led to lower ELN (46% and 48%) versus preoperative chemotherapy alone (66%). Multivariate analysis showed that patients who had ≥12 nodes removed had better OS (Hazard Ratio 0.843 [95 confidence interval 0.820–0.867]). In addition, care at a high-volume facility, care at an academic facility, private insurance, and income ≥$63,000 were all associated with improved OS. Higher ELN count is associated with OS in patients with esophageal cancer. Patients who receive care at high-volume centers and academic centers are more likely to undergo more extensive lymphadenectomy. All centers should strive to examine at least 12 nodes to provide a quality esophagectomy.

Download Full-text

Racial Disparities in Breast Cancer Persist Despite Early Detection: Analysis of Stage 1 Breast Cancer Treatment in the National Cancer Database and Effects of Private Insurance Status on Disparities

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2017.07.276 ◽

2017 ◽

Vol 225 (4) ◽

pp. S125 ◽

Cited By ~ 1

Author(s):

Barbara A. Wexelman ◽

Ethan Hoppe ◽

Lala R. Hussain ◽

Erk Dunki-Jacobs ◽

Ching Ho ◽

...

Keyword(s):

Breast Cancer ◽

Early Detection ◽

Cancer Treatment ◽

Racial Disparities ◽

Private Insurance ◽

Breast Cancer Treatment ◽

Insurance Status ◽

National Cancer Database ◽

Detection Analysis ◽

Stage 1

Download Full-text

A National Cancer Database analysis of treatment utilization and associated outcomes in elderly patients with locally advanced esophageal cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.4_suppl.138 ◽

2017 ◽

Vol 35 (4_suppl) ◽

pp. 138-138

Author(s):

Gregory Riccardo Vlacich ◽

Pamela Parker Samson ◽

Stephanie Mabry Perkins ◽

Michael Charles Roach ◽

Parag J. Parikh ◽

...

Keyword(s):

Esophageal Cancer ◽

Elderly Patients ◽

Locally Advanced ◽

Palliative Therapy ◽

Female Gender ◽

Treatment Utilization ◽

National Cancer Database ◽

Advanced Esophageal Cancer ◽

Trimodality Therapy ◽

Locally Advanced Esophageal Cancer

138 Background: Elderly patients with locally advanced esophageal cancer pose a therapeutic challenge since definitive treatment involves aggressive combined-modality therapy. Whether these individuals are offered or benefit from these approaches in the modern, trimodality era has not been widely explored. Methods: Patients ≥ 70 years old with clinical stage II and III esophageal cancer diagnosed between 1998 and 2012 were identified from the National Cancer Database and stratified based on treatment. Variables independently associated with treatment utilization were evaluated using logistic regression and mortality hazard evaluated using Cox-proportional hazards analysis. The primary aim was to compare overall survival by treatment group. The secondary aim was to identify variables associated with receiving each modality. Results: A total of 21,593 patients were identified. Median and maximum ages were 77 and 90 respectively. In 12.9%, no therapy was delivered, 24.3% received palliative therapy, 37.1% received definitive chemoradiation, 5.6% received esophagectomy alone, and 10.0% received trimodality therapy. On multivariate analysis, age ≥ 80 (OR 0.73, p < 0.001), female gender (OR 0.81, p < 0.001), and treatment at high-volume centers (OR 0.83, p = 0.008) were associated with a decreased likelihood of palliative therapy over no treatment. Age ≥ 80 (OR 0.15, p < 0.001), female gender (OR 0.80, p = 0.03), and non-Caucasian race (OR 0.63, p < 0.001) were associated with decreased trimodality use compared to definitive chemoradiation. Each treatment independently demonstrated improved survival compared to no therapy: palliative treatment (HR 0.49), concurrent chemoradiation (HR 0.36), esophagectomy (HR 0.31), trimodality therapy (HR 0.25), all p < 0.001. Conclusions: Any therapy, including palliative care, was associated with improved survival compared to no treatment in elderly patients with esophageal cancer. Subsets of patients are less likely to receive aggressive therapy based on social and institutional factors. Care should be taken to not unnecessarily deprive elderly patients of treatment that may improve survival.

Download Full-text

Baseline features predicting receipt of chemotherapy in metastatic esophageal cancer: A National Cancer Database analysis of 12,370 patients.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.4_suppl.316 ◽

2020 ◽

Vol 38 (4_suppl) ◽

pp. 316-316

Author(s):

Nicholas Manguso ◽

Sungjin Kim ◽

Andrew Eugene Hendifar ◽

Samuel J. Klempner ◽

Joseph Chao ◽

...

Keyword(s):

Esophageal Cancer ◽

Female Gender ◽

Time Dependent ◽

Median Income ◽

National Cancer Database ◽

Database Analysis ◽

Data Set ◽

Academic Center ◽

Comorbidity Index ◽

Multivariable Analyses

316 Background: We investigated predictors for chemotherapy (CTX) and prognostic variables in a large metastatic esophageal cancer (mEC) patient data set. Methods: We interrogated the National Cancer Database between 2004-2015 and included patients (pts) with M1 disease who had known CTX status (received or did not receive CTX). Univariable and multivariable analyses were performed, and a logistic regression model was used to estimate the effect of CTX with adjustment for potential confounders. Results: We included 12,370 mEC patients with available CTX status for multivariable analyses. Predictors for CTX treatment included year of diagnosis 2010-2014 (odds ratio (OR) 1.29, 95% confidence interval (CI) 1.17-1.43), median income > $46,000 (OR 1.49, 1.27-1.75), and node-positivity (OR 1.35, 1.20-1.52; all p < 0.05), while female gender (OR 0.86, 0.76-0.98), black race (OR 0.76, 0.67-0.93), uninsured (OR 0.41, 0.33-0.52), and Charlson Comorbidity Index (CCI) ≥2 (OR 0.61, 0.50-0.74) predicted for lower odds of receiving CTX (all p < 0.05). Median OS for pts receiving CTX was 9.53 mos (9.33-9.72) vs. 2.43 mos (2.27-2.60) with no CTX (p < 0.001). Modeling the effect of CTX to OS using a time-dependent coefficient showed that CTX was associated with improved OS up to 10 months, after which there is no significant effect on OS. Independent predictors of OS included treatment at an academic center (hazard ratio (HR) 0.91, 0.87-0.94), CCI ≥2 (HR 1.16, 1.07-1.26), and uninsured status (HR 1.20, 1.09-1.31). Conclusions: We identified several predictors for receipt of CTX and OS in pts with mEC. The benefit of CTX on OS is time-dependent and favors early initiation. Focused outreach in lower income and underinsured patients is critical as receipt of CTX is associated with improved OS.

Download Full-text