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. 2019 Feb;10(1):74-84.
doi: 10.21037/jgo.2018.10.04.

Treatment disparities affect outcomes for patients with stage I esophageal cancer: a national cancer data base analysis

Amy C Moreno  1 , Ning Zhang  2 , Vivek Verma  3 , Sharon H Giordano  2 , Steven H Lin  1
Affiliations
Free PMC article

Treatment disparities affect outcomes for patients with stage I esophageal cancer: a national cancer data base analysis

Amy C Moreno et al. J Gastrointest Oncol. 2019 Feb.
Free PMC article

Abstract

Background: To examine patterns of care and outcomes for patients with stage I esophageal cancer (EC) in the United States.

Methods: We identified patients in the National Cancer Data Base diagnosed with stage I EC from 2004 to 2012 and grouped them by primary treatment: esophagectomy (Eso), local excision (LE), concurrent chemoradiation (CRT), or observation (Obs). Multinomial logistic regression was used to predict receipt of treatments. Overall survival (OS) was estimated by Kaplan-Meier methods adjusted for inverse probability of treatment weighting (IPTW) and Cox proportional hazard regressions.

Results: Of 5,480 patients, 2,312 (42%) underwent Eso, 1,250 (23%) LE, 758 (14%) CRT, and 1,160 (21%) Obs. LE use increased over time from 17% to 29% while Obs declined from 26% to 19%. Patients least likely to undergo surgery were older, had greater comorbidity, were uninsured, were treated at non-academic centers, and were Black. The rate of surgery for Black patients was half of that for White patients (33% vs. 67%). Postoperative mortality rates were higher after Eso vs. LE at 30 days (2.9% vs. 0.5%; P<0.001) and at 90 days (5.5% vs. 1.4%, P<0.001). Five-year OS was 59% with Eso, 63% LE, 29% CRT, and 31% Obs (P<0.001). On multivariate analysis, outcomes were best after LE [vs. Eso: hazard ratio (HR) =1.15, 95% CI: 1.01-1.30, P=0.037; CRT: HR =2.41, 95% CI: 2.09-2.78, P<0.001; Obs: HR =3.79, 95% CI: 3.33-4.32, P<0.001).

Conclusions: Disparities are evident in the care of patients with stage I EC throughout the United States. LE was associated with favorable outcomes compared to Eso, CRT, and Obs.

Keywords: Stage I esophageal cancer; chemoradiation (CRT); disparities; esophagectomy.

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Conflict of interest statement

Conflicts of Interest: SH Lin has research funding from Elekta, STCube Pharmaceuticals, Peregrine, Hitachi Chemical Inc., and Roche/Genentech, has served as consultant for AstraZeneca, and received honoraria from US Oncology and ProCure.

Figures

Figure 1
Figure 1
Flow diagram. CRT, chemoradiation; EBRT, external beam radiation therapy.
Figure 2
Figure 2
Temporal trends in treatment selection for stage I esophageal cancer from 2004 through 2012. CRT, chemoradiation; Eso, esophagectomy; LE, local excision; Obs, observation.
Figure 3
Figure 3
Inverse probability of treatment weighting-adjusted Kaplan-Meier 5-year overall survival estimates by treatment groups. Risk table appears below graph. CRT, chemoradiation; Eso, esophagectomy; LE, local excision; Obs, observation.
See this image and copyright information in PMC

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