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Racial Differences in Surgical Evaluation, Treatment, and Outcome of Locoregional Esophageal Cancer: A Population-Based Analysis of Elderly Patients

From the Center for Clinical Decision Sciences, Department of Public Health, Erasmus MC, Rotterdam, the Netherlands; and Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA

Address reprint requests to E.W. Steyerberg, PhD, Department of Public Health, Erasmus MC, PO Box 1738, 3000 DR Rotterdam, the Netherlands; e-mail: E.Steyerberg{at}ErasmusMC.nl

PURPOSE: We investigated racial disparities in access to surgical evaluation, receipt of surgery, and survival among elderly patients with locoregional esophageal cancer.

METHODS: We selected 2,946 white patients and 367 black patients who were older than 65 years and had clinically locoregional esophageal cancer in the Surveillance, Epidemiology, and End Results (SEER) registry (1991 to 1999). Treatment and outcome data were obtained from the linked SEER-Medicare databases. We used logistic regression analysis to estimate odds ratios (ORs) for being seen by a surgeon and for undergoing surgery. Cox proportional hazards analyses were performed to estimate hazard ratios (HRs) for survival adjusted for medical, nonmedical, and treatment characteristics.

RESULTS: The rate of surgery for black patients was half that of white patients (25% v 46%; OR, 0.38; P < .001), which was caused by both a lower rate of seeing a surgeon (70% v 78%; OR, 0.66; P < .001) and a lower rate of surgery once seen (35% v 59%; OR, 0.38; P < .001). These racial disparities were only partly explained by differences in patient and cancer characteristics, and not by nonmedical factors, such as socioeconomic status. The 2-year survival rate was lower for black patients (18% v 25%; HR, 1.18; P = .004), but this racial difference disappeared when corrected for treatment received (adjusted HR, 1.02; P = .80).

CONCLUSION: Underuse of potentially curative surgery is an important potential explanation for the poorer survival of black patients with locoregional esophageal cancer. Barriers to surgical evaluation and treatment need to be reduced, whether related to patient or healthcare system factors.

E.W.S. was supported by a fellowship from the Royal Netherlands Academy for Arts and Sciences. C.C.E. was supported in part by a Dunkin' Donuts Rising Star award.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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