Racial differences in surgical evaluation, treatment, and outcome of locoregional esophageal cancer: a population-based analysis of elderly patients.
OBJECTIVE
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).


CONCLUSIONS
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.
Steyerberg
Ewout W
EW
Department of Public Health, Erasmus MC, PO Box 1738, 3000 DR Rotterdam, the Netherlands. E.Steyerberg@ErasmusMC.nl
Earle
Craig C
CC
Neville
Bridget A
BA
Weeks
Jane C
JC
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D044383:Black People; D004938:Esophageal Neoplasms / Q000208:ethnology* / Q000473:pathology / Q000601:surgery*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012044:Regression Analysis; D018426:SEER Program / Q000706:statistics & numerical data*; D012923:Social Class; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*; D016019:Survival Analysis; D014481:United States; D044465:White People; D001741:Black or African American