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Noureldin M, Rubenstein JH, Urias E, Berinstein JA, Cohen-Mekelburg S, Saini SD, Higgins PD, Waljee AK. Racial Disparity in Esophageal Squamous Cell Carcinoma Treatment and Survival in the United States. Am J Gastroenterol 2024; 119:830-836. [PMID: 37975573 DOI: 10.14309/ajg.0000000000002606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Esophageal squamous cell carcinoma (ESCC) has a higher incidence and prevalence than esophageal adenocarcinoma among Black individuals in the United States. Black individuals have lower ESCC survival. These racial disparities have not been thoroughly investigated. We examined the disparity in treatment and survival stratified by ESCC stage at diagnosis. METHODS The Surveillance, Epidemiology, and End Results database was queried to identify patients with ESCC between 2000 and 2019. The identified cohort was divided into subgroups by race. Patient and cancer characteristics, treatment received, and survival rates were compared across the racial subgroups. RESULTS A total of 23,768 patients with ESCC were identified. Compared with White individuals, Black individuals were younger and had more distant disease during diagnosis (distant disease: 26.7% vs 23.8%, P < 0.001). Black individuals had lower age-standardized 5-year survival for localized (survival % [95% confidence interval]: 19.3% [16-22.8] vs 27.6% [25.1-30.2]), regional (14.3% [12-16.7] vs 21.1% [19.6-22.7]), and distant (2.9% [1.9-4.1] vs 6.5% [5.5-7.5]) disease. Black individuals were less likely to receive chemotherapy (54.7% vs 57.5%, P = 0.001), radiation (58.5% vs 60.4%, P = 0.03), and surgery (11.4% vs 16.3%, P < 0.0001). DISCUSSION Black individuals with ESCC have a lower survival rate than White individuals. This could be related to presenting at a later stage but also disparities in which treatments they receive even among individuals with the same stage of disease. To what extent these disparities in receipt of treatment is due to structural racism, social determinants of health, implicit bias, or patient preferences deserves further study.
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Affiliation(s)
- Mohamed Noureldin
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Joel H Rubenstein
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Cancer Control and Population Sciences Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Esteban Urias
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeffrey A Berinstein
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Shirley Cohen-Mekelburg
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Sameer D Saini
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Peter D Higgins
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Akbar K Waljee
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Center for Global Health Equity, University of Michigan, Ann Arbor, Michigan, USA
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Salti I, Petesch T, Naffouje SA, Kamarajah SK, Dahdaleh F. Effect of Health Disparities on Refusal of Trimodality Therapy in Localized Esophageal Adenocarcinoma: A Propensity Score Matched Analysis of the National Cancer Database. Am Surg 2023; 89:4644-4653. [PMID: 36112751 DOI: 10.1177/00031348221117040] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
BACKGROUND Factors associated with refusal of multimodality therapy in patients with localized esophageal adenocarcinoma (EA) remain unknown. We hypothesized that sociodemographic disparities affect decision to pursue optimal trimodally therapy for patients with EA. METHODS NCDB for esophageal cancer (2004-2017) was utilized. Included were patients diagnosed with cT3-T4 cN0 or cTany N1-3 EA of the mid-lower esophagus. Annual institutional esophagectomy volumes were categorized as low (<20/year) and high (≥20/year). Conditional logistic regression was used to identify predictors of refusal of offered treatment. Kaplan Meier method was used to compare survival. RESULTS 13 091 patients met selection criteria, mean age was 62.4 ± 9.6 years and 11 581 (88.5%) were males. 633 (4.8%) patients refused at least one component of recommended treatment (chemotherapy, radiation, and esophagectomy), most commonly refusal of surgery (N = 554, 4.2%). On multivariable analysis, factors predictive of treatment refusal included older age, female gender, black race, no insurance, low income (below poverty), mid-esophageal tumors, and treatment at low-volume centers. Patients who were recommended treatment but refused had significantly worse survival than those who adhered to treatment (median 23.1 ± 1.1 vs. 32.1 ± 1.2 months; P < .001). CONCLUSIONS In this study, sociodemographic disparities and center volume were among factors predictive of therapy refusal in patients with localized esophageal adenocarcinoma. While understanding potential reasons for treatment refusal is critical, this data suggests that socioeconomic variables may drive patient decisions.
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Affiliation(s)
- Isabella Salti
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
| | - Taylor Petesch
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Samer A Naffouje
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Sivesh K Kamarajah
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
- Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
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Zhang S, He J, Liu J. Characteristics and survival of patients with gynecological cancers who refuse radiotherapy: a retrospective cohort study. BMC Womens Health 2023; 23:562. [PMID: 37915037 PMCID: PMC10621229 DOI: 10.1186/s12905-023-02720-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/18/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Radiotherapy improves survival for many cancer patients. However, some patients still refuse radiotherapy despite the recommendations of their physicians. We aimed to investigate the impact of refusing recommended radiotherapy on overall survival in patients with gynecological cancers (GC) and attempted to describe what characteristics are associated with the refusal of radiotherapy. METHODS Data were extracted from the Surveillance, Epidemiology and End Result (SEER) database for patients who were diagnosed with GC and recommended for radiotherapy between 1988 and 2016. Kaplan-Meier and multivariate Cox regression analyses were utilized to analyze the impact of refusal of radiotherapy on overall survival. Univariate and multivariate logistic regression analyses were used to identify characteristics associated with refusal of radiotherapy. RESULTS In total, 1,226 of 208,093 patients (0.6%) refused radiotherapy. Multivariate Cox regression analysis showed that refusal of radiotherapy was associated with poorer overall survival in GC patients with stage I/II [hazard ratio (HR) = 1.64; 95% confidence interval (CI), 1.50-1.79], but may not affect overall survival in patients with stage III/IV (HR = 1.03; 95%CI, 0.84-1.25). Multivariate logistic regression analysis demonstrated that factors such as older age (40-65 years, > 65 years), unmarried status (divorced, single, widowed), higher foreign-born rate (1.87-2.82%, 1.51-2.19), refusal of surgery (recommended but not performed), and higher grade (poorly differentiated, undifferentiated/anaplastic) may increase the likelihood of refusing radiotherapy (all P < 0.05). Factors that may reduce the likelihood of refusing radiotherapy include higher income (> 42,810$), lower grade (well-differentiated), primary site of ovarian cancer, and no/unknown chemotherapy (all P < 0.05). CONCLUSION Refusal of radiotherapy is related to worse overall survival in GC patients with stage I/II, and many characteristics may affect a patient's choice of refusal of radiotherapy.
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Affiliation(s)
- Shuangli Zhang
- Department of Gynecology, Beijing Ditan Hospital, Capital Medical University, No.8 Jingshun East Street, Chaoyang District, Beijing, 100200, China
| | - Jie He
- Department of Gynecology, Beijing Liangxiang Hospital, Capital Medical University, Beijing, 102401, China
| | - Jun Liu
- Department of Gynecology, Beijing Ditan Hospital, Capital Medical University, No.8 Jingshun East Street, Chaoyang District, Beijing, 100200, China.
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Kakish HH, Loftus AW, Ahmed FA, Elshami M, Ocuin LM, Rothermel LD, Hoehn RS. Patient and provider factors predict non-surgical management for complex upper gastrointestinal cancers. Surgery 2023; 174:618-625. [PMID: 37391325 DOI: 10.1016/j.surg.2023.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/05/2023] [Accepted: 05/24/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Surgery is the only potentially curative treatment for non-metastatic upper gastrointestinal cancers. We analyzed patient and provider characteristics associated with non-surgical management. METHODS We queried the National Cancer Database for patients with upper gastrointestinal cancers from 2004 to 2018 who underwent surgery, refused surgery, or for whom surgery was contraindicated. Multivariate logistic regression identified factors associated with surgery being refused or contraindicated, and Kaplan-Meier curves assessed survival. RESULTS We identified 249,813 patients based on our selection criteria-86.3% had surgery, 2.4% refused, and for 11.3%, surgery was contraindicated. Median overall survival was 48.2 months for patients who underwent surgery versus 16.3 and 9.4 months for the refusal and contraindicated groups. Medical and non-medical factors predicted both surgery refusals and contraindications, such as increasing age (odds ratio = 1.07 and 1.03, respectively, P < .001), Black race (odds ratio = 1.72 and 1.45, P < .001), comorbidities (Charlson-Deyo score 2+, odds ratio = 1.18 and 1.66, P < .001), low socioeconomic status (odds ratio = 1.70 and 1.40, P < .001), no health insurance (odds ratio = 3.26 and 2.34, P < .001), community cancer programs (odds ratio = 1.43 and 1.40, P < .001), low volume facilities (odds ratio = 1.82 and 1.52, P < .001), and stage 3 disease (odds ratio = 1.51 and 6.50, P < .001). On subset analysis (excluding patients age >70, Charlson-Deyo score 2+, and stage 3 cancer), non-medical predictors of both outcomes were similar. CONCLUSION Refusal of and medical contraindications for surgery profoundly impact overall survival. The same factors (ie, race, socioeconomic status, hospital volume, and hospital type) predict these outcomes. These findings suggest variation and potential bias that may exist between physicians and patients discussing cancer surgery.
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Affiliation(s)
- Hanna H Kakish
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH. https://twitter.com/HannaKakish
| | - Alexander W Loftus
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH
| | - Fasih Ali Ahmed
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH
| | - Mohamedraed Elshami
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH
| | - Richard S Hoehn
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, OH.
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Chi CL, Gao X, Hsieh HY, Cheng YH, Yang ZH, Chao YK. Survival Outcomes of Patients with Esophageal Cancer Who Did Not Proceed to Surgery after Neoadjuvant Treatment. Cancers (Basel) 2023; 15:4049. [PMID: 37627076 PMCID: PMC10452185 DOI: 10.3390/cancers15164049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/28/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND This retrospective study examined outcomes in esophageal squamous cell carcinoma (ESCC) patients who did not undergo surgical resection after neoadjuvant chemoradiotherapy (nCRT). METHODS Patients receiving nCRT between 2012 and 2020 were divided into two groups: group 1 (scheduled surgery) and group 2 (no surgery). Group 2 was further categorized into subgroups based on reasons for not proceeding to surgery: group 2a (disease progression), group 2b (poor general conditions), and group 2c (patient refusal). Overall survival (OS) was the primary outcome. RESULTS Group 1 comprised 145 patients, while subgroups 2a, 2b, and 2c comprised 24, 16, and 31 patients, respectively. The 3-year OS rate was significantly lower in group 2 compared with group 1 (34% versus 56%, p < 0.001). A subgroup analysis showed varying 3-year OS rates: 13% for group 2a, 25% for group 2b, and 58% for group 2c (p < 0.001). Propensity score matching for group 2c and group 1 revealed no significant difference in 3-year OS rates (p = 0.91). CONCLUSION One-third of ESCC patients receiving nCRT did not undergo surgical resection. Overall survival in this group was generally poorer, except for those who refused surgery (group 2c).
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Affiliation(s)
- Chun-Ling Chi
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan 333, Taiwan; (C.-L.C.); (X.G.); (H.-Y.H.); (Y.-H.C.); (Z.-H.Y.)
| | - Xing Gao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan 333, Taiwan; (C.-L.C.); (X.G.); (H.-Y.H.); (Y.-H.C.); (Z.-H.Y.)
- Department of Surgery, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands
| | - Hsiang-Yu Hsieh
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan 333, Taiwan; (C.-L.C.); (X.G.); (H.-Y.H.); (Y.-H.C.); (Z.-H.Y.)
| | - Yi-Hsuan Cheng
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan 333, Taiwan; (C.-L.C.); (X.G.); (H.-Y.H.); (Y.-H.C.); (Z.-H.Y.)
| | - Zhi-Hao Yang
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan 333, Taiwan; (C.-L.C.); (X.G.); (H.-Y.H.); (Y.-H.C.); (Z.-H.Y.)
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan 333, Taiwan; (C.-L.C.); (X.G.); (H.-Y.H.); (Y.-H.C.); (Z.-H.Y.)
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Soon JJY, Zhao Y, Shannon NB, Tan JTH. Adherence to Multidisciplinary Tumor Board Recommendations in Patients With Curable Esophageal and Gastric Cancers. J Gastrointest Cancer 2023; 54:614-622. [PMID: 35759206 DOI: 10.1007/s12029-022-00847-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Multidisciplinary tumor board (MDT) discussion is standard practice in the management of Upper Gastrointestinal (UGI) cancers. However, poor adherence to MDT recommendations may account for the lack of improved oncological outcomes with MDTs. We aim to quantify adherence rates and compare outcomes between adherent and non-adherent patients. METHODS We included all patients with potentially curable primary UGI carcinomas who were discussed at UGI MDT from 2017 to 2018. MDT recommendations were compared to actual treatment received. Oncological and survival outcomes were compared between both groups. RESULTS Amongst 153 patients, 64 (41.8%) were non-adherent to MDT recommendations. Reasons for non-adherence were patient refusal (50.0%), treatment-related complications (31.3%), disease factors (17.2%) and clinician decision (1.56%). Univariate analysis showed that non-adherent patients were older (71.6 vs 65.2 years, p < 0.001), with higher clinical stage at point of diagnosis (p = 0.028), pathological stage after resection (p < 0.001) and were more likely to be recommended for multimodal therapy. No significant factors were associated with non-adherence at multivariate analysis. Non-adherent patients had worse median overall survival (19.5 months) compared to adherent patients (not reached at follow-up) with both unmatched and propensity-score matched analysis. Patients who received only part of the intended adjuvant chemotherapy course had worse median overall survival and disease-free survival compared to patients who completed or did not initiate adjuvant chemotherapy. CONCLUSIONS Non-adherence to MDT recommendations was associated with advanced age and tumor stage, and potentially contributes to the worse oncological outcomes in a group of patients already predisposed to poor outcomes.
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Affiliation(s)
- Joel Jia Yi Soon
- Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore.
| | - Yue Zhao
- Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore
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Delman AM, Ammann AM, Turner KM, Vaysburg DM, Van Haren RM. A narrative review of socioeconomic disparities in the treatment of esophageal cancer. J Thorac Dis 2021; 13:3801-3808. [PMID: 34277070 PMCID: PMC8264668 DOI: 10.21037/jtd-20-3095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/31/2020] [Indexed: 12/11/2022]
Abstract
The persistent challenges of disparities in healthcare have led to significantly distinct outcomes among patients from different racial, ethnic, and underserved populations. Esophageal Cancer, not unlike other surgical diseases, has seen significant disparities in care. Esophageal cancer is currently the 6th leading cause of death from cancer and the 8th most common cancer in the world. Surgical disparities in the care of patients with Esophageal Cancer have been described in the literature, with a prevailing theme associating minority status with worse outcomes. The goal of this review is to provide an updated account of the literature on disparities in Esophageal Cancer presentation and treatment. We will approach this task through a conceptual framework that highlights the five main themes of surgical disparities: patient-level factors, provider-level factors, system and access issues, clinical care and quality, and postoperative outcomes, care and rehabilitation. All five categories play a complex role in the delivery of high-quality, equitable care for patients with Esophageal Cancer. While describing disparities in care is the first step to correcting them, moving forward, we should focus on developing effective interventions to mitigate disparities, policies linking disparities to quality-of-care metrics, and delivery system change to enable minority patients to more easily access high volume centers.
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Affiliation(s)
- Aaron M Delman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Allison M Ammann
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kevin M Turner
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dennis M Vaysburg
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert M Van Haren
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Parsons M, Tao R. ASO Author Reflections: The Impact of Local Therapy on Non-metastatic Esophageal Cancer. Ann Surg Oncol 2020; 27:818-819. [DOI: 10.1245/s10434-020-08808-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Indexed: 12/16/2022]
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