Abstract
Purpose
Blacks have a higher mortality rate than whites from esophageal cancer, but the reasons underlying this disparity remain unclear. In this study, we used a national sample of patients with resectable esophageal cancer to assess the extent to which racial inequalities in care can explain outcome disparities.
Methods
We identified all non-Hispanic white and black patients diagnosed with T0–T2, node-negative esophageal cancer between 1988 and 2003 from the Surveillance, Epidemiology, and End Results registry. Racial differences in esophageal-specific survival were assessed using the Kaplan-Meier method. We performed Cox regression to test for racial differences in survival after adjusting for potential confounders and to assess the extent to which disparities can be explained by later diagnosis or treatment inequalities.
Results
A total of 1522 patients were included in the study. Blacks had worse esophageal-specific survival rates than whites (37% vs 60% 5-year survival; P < .0001). Blacks were more likely to be diagnosed at a more advanced stage and to have squamous cell tumors, but were less likely to undergo surgery. In multivariate regression controlling for age, sex, marital status, histology, and tumor location, black race was associated with worse survival. When tumor status, surgery, and radiotherapy were added to the model, race was no longer significantly associated with survival.
Conclusion
These data suggest that blacks are at greater risk of death from esophageal cancer. While the disparity is due in part to differences in tumor histology, diagnosis at an earlier stage and higher rates of surgery among blacks could reduce this survival disparity.
Similar content being viewed by others
References
Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, 2007. CA Cancer J Clin 2007; 57:43–66
DeMeester SR. Adenocarcinoma of the esophagus and cardia: a review of the disease and its treatment. Ann Surg Oncol 2006; 13:12–30
Kubo A, Corley DA. Marked regional variation in adenocarcinomas of the esophagus and the gastric cardia in the United States. Cancer 2002; 95:2096–102
Howe HL, Wu X, Ries LA, et al. Annual report to the nation on the status of cancer, 1975–2003, featuring cancer among U.S. Hispanic/Latino populations. Cancer 2006; 107:1711–42
Ward E, Jemal A, Cokkinides V, Singh GK, Cardinez C, Ghafoor A, Thun M. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin 2004; 54:78–93
Baquet CR, Commiskey P, Mack K, Meltzer S, Mishra SI. Esophageal cancer epidemiology in blacks and whites: racial and gender disparities in incidence, mortality, survival rates and histology. J Natl Med Assoc 2005; 97:1471–8
Blot WJ, Devesa SS, Kneller RW, Fraumeni JF Jr. Rising incidence of adenocarcinoma of the esophagus and gastric cardia. JAMA 1991; 265:1287–9
Blot WJ, Devesa SS, Fraumeni JF Jr. Continuing climb in rates of esophageal adenocarcinoma: an update. JAMA 1993; 270:1320
Blot WJ, McLaughlin JK. The changing epidemiology of esophageal cancer. Semin Oncol 1999; 26:2–8
Devesa SS, Blot WJ, Fraumeni JF Jr. Changing patterns in the incidence of esophageal and gastric carcinoma in the United States. Cancer 1998; 83:2049–53
National Healthcare Disparities Report. Rockville MD: US Dept. of Health and Human Services. Agency for Health Care Research and Quality; 2005
Surveillance, Epidemiology, and End Results (SEER) program public-use data (1973–2000) National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch. 2006
Ries LAG, Harkins D, Krapcho M, et al. SEER Cancer Statistics Review, 1975–2003. 2006
AJCC Cancer Staging. New York: Springer-Verlag; 2002
Kaplan E, Meier M. Nonparametric estimation for incomplete observations J Am Stat Assoc 1958; 53:457–81
Wisnivesky JP, McGinn T, Henschke C, Hebert P, Iannuzzi MC, Halm EA. Ethnic disparities in the treatment of stage I non-small cell lung cancer. Am J Respir Crit Care Med 2005; 171:1158–63
Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. N Engl J Med 1999; 341:1198–205
Baldwin LM, Dobie SA, Billingsley K, et al. Explaining black-white differences in receipt of recommended colon cancer treatment. J Natl Cancer Inst 2005; 97:1211–20
Schrag D, Cramer LD, Bach PB, Begg CB. Age and adjuvant chemotherapy use after surgery for stage III colon cancer. J Natl Cancer Inst 2001; 93:850–7
Pearlman DN, Rakowski W, Ehrich B, Clark MA. Breast cancer screening practices among black, Hispanic, and white women: reassessing differences. Am J Prev Med 1996; 12:327–37
McCarthy EP, Burns RB, Coughlin SS, et al. Mammography use helps to explain differences in breast cancer stage at diagnosis between older black and white women. Ann Intern Med 1998; 128:729–36
Margolis ML, Christie JD, Silvestri GA, Kaiser L, Santiago S, Hansen-Flaschen J. Racial differences pertaining to a belief about lung cancer surgery: results of a multicenter survey. Ann Intern Med 2003; 139:558–63
Demark-Wahnefried W, Strigo T, Catoe K, Conaway M, Brunetti M, Rimer BK, Robertson CN. Knowledge, beliefs, and prior screening behavior among blacks and whites reporting for prostate cancer screening. Urology 1995; 46:346–51
Glanz K, Resch N, Lerman C, Rimer BK. Black-white differences in factors influencing mammography use among employed female health maintenance organization members. Ethn Health 1996; 1:207–20
Weisse CS, Sorum PC, Sanders KN, Syat BL. Do gender and race affect decisions about pain management? J Gen Intern Med 2001; 16:211–17
van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med 2000; 50:813–28
Dovidio JF, ed. Stereotyping. MA: MIT Press, 1999
Einbinder LC, Schulman KA. The effect of race on the referral process for invasive cardiac procedures. Med Care Res Rev 2000; 57 Suppl 1:162–80
Davis TC, Williams MV, Marin E, Parker RM, Glass J. Health literacy and cancer communication. CA Cancer J Clin 2002; 52:134–49
Ayanian JZ, Chrischilles EA, Fletcher RH, et al. Understanding cancer treatment and outcomes: the Cancer Care Outcomes Research and Surveillance Consortium. J Clin Oncol 2004; 22:2992–6
Freid VM, Prager K, MacKay AP, et al., ed. Chartbook on Trends in the Health of Americans. United States, 2003. Hyattsville, MD: National Center for Health Statistics, 2003
Brown LM, Hoover RN, Greenberg RS, et al. Are racial differences in squamous cell esophageal cancer explained by alcohol and tobacco use? J Natl Cancer Inst 1994; 86:1340–5
Brown LM, Silverman DT, Pottern LM, et al. Adenocarcinoma of the esophagus and esophagogastric junction in white men in the United States: alcohol, tobacco, and socioeconomic factors. Cancer Causes Control 1994; 5:333–40
Giuli R, Gignoux M. Treatment of carcinoma of the esophagus. Retrospective study of 2,400 patients. Ann Surg 1980; 192:44–52
Holscher AH, Bollschweiler E, Schneider PM, Siewert JR. Prognosis of early esophageal cancer. Comparison between adeno- and squamous cell carcinoma. Cancer 1995; 76:178–86
Siewert JR, Stein HJ, Feith M, Bruecher BL, Bartels H, Fink U. Histologic tumor type is an independent prognostic parameter in esophageal cancer: lessons from more than 1,000 consecutive resections at a single center in the Western world. Ann Surg 2001; 234:360–7; discussion 368–9
Stein HJ, Feith M, Bruecher BL, Naehrig J, Sarbia M, Siewert JR. Early esophageal cancer: pattern of lymphatic spread and prognostic factors for long-term survival after surgical resection. Ann Surg 2005; 242:566–73; discussion 573–5
Mariette C, Finzi L, Piessen G, Van Seuningen I, Triboulet JP. Esophageal carcinoma: prognostic differences between squamous cell carcinoma and adenocarcinoma. World J Surg 2005; 29:39–45
Smith Sehdev AE, Hutchins GM. Problems with proper completion and accuracy of the cause-of-death statement. Arch Intern Med 2001; 161:277–84
Kircher T, Nelson J, Burdo H. The autopsy as a measure of accuracy of the death certificate. N Engl J Med 1985; 313:1263–9
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Greenstein, A.J., Litle, V.R., Swanson, S.J. et al. Racial Disparities in Esophageal Cancer Treatment and Outcomes. Ann Surg Oncol 15, 881–888 (2008). https://doi.org/10.1245/s10434-007-9664-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-007-9664-5