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

Abstract

Background

Treatment guidelines for stage I–III esophageal cancer indicate that management should include surgery in appropriate patients. Variations in utilization of surgery may contribute to racial differences observed in survival. We sought to identify factors associated with racial disparities in surgical resection of esophageal cancer and evaluate associated survival differences.

Methods

Patients diagnosed with stage I–III esophageal cancer from 2004 to 2015 were identified using the National Cancer Database. Matched patient cohorts were created to reduce confounding. Multivariate logistic regression was used to identify factors associated with receipt of surgery. Multi-level modeling was performed to control for random effects of individual hospitals on surgical utilization.

Results

A total of 60,041 patients were included (4402 black; 55,639 white). After 1:1 matching, there were 5858 patients evenly distributed across race. For all stages, significantly fewer black than white patients received surgery. Black race independently conferred lower likelihood of receiving surgery in single-level multivariable analysis (OR (95% CI); stage I, 0.67 (0.48–0.94); stage II, 0.76 (0.60–0.96); stage III, 0.62 (0.50–0.76)) and after controlling for hospital random effects. Hospital-level random effects accounted for one third of the unexplained variance in receipt of surgery. Risk-adjusted 1-, 3-, and 5-year mortality was higher for patients who did not undergo surgery.

Conclusion

Black patients with esophageal cancer are at higher risk of mortality compared to white patients. This increased risk may be influenced by decreased likelihood of receiving surgical intervention for resectable disease, in part because of between-hospital differences. Improving access to surgical care may improve disparities in esophageal cancer survival.

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Authors

Contributions

Protocol/project development: SL Savitch, TR Grenda, SW Cowan, NR Evans

Data collection or management: SL Savitch, TR Grenda, NR Evans

Data analysis and interpretation: SL Savitch, TR Grenda, W Scott, SW Cowan, J Posey, EP Mitchell, SJ Cohen, CJ Yeo, NR Evans

Manuscript writing and editing: SL Savitch, TR Grenda, W Scott, SW Cowan, J Posey, EP Mitchell, SJ Cohen, CJ Yeo, NR Evans

Corresponding author

Correspondence to Samantha L. Savitch.

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Meeting presentation: Digestive Disease Week, May 2019, San Diego, CA

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Savitch, S.L., Grenda, T.R., Scott, W. et al. Racial Disparities in Rates of Surgery for Esophageal Cancer: a Study from the National Cancer Database. J Gastrointest Surg 25, 581–592 (2021). https://doi.org/10.1007/s11605-020-04653-z

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Keywords

  • Esophageal cancer
  • NCDB
  • Racial disparities
  • Esophagectomy