Racial disparities in access to surgical evaluation

African Americans with esophageal cancer are half as likely as whites to be seen by a surgeon and to receive life-prolonging surgery, a new study shows.

The study, which examined racial disparities in access to surgical evaluation, receipt of surgery, and survival among older patients with esophageal cancer, found that only 25% of African-American patients received potentially curative surgery, compared to 46% of white patients. The study will be published in the January 20 issue of the Journal of Clinical Oncology (JCO).

"Our study showed that black patients are less likely to be seen by a surgeon, and if seen, less likely to undergo surgery," said Ewout W. Steyerberg, PhD, Center for Clinical Decision Sciences, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands, and lead author of the study. "We were particularly surprised by the two-fold difference in rate of surgery, which may explain why African Americans experience a lower rate of survival."

Researchers reported that African Americans were generally undertreated for their disease. Twenty percent of African-American patients received radiotherapy as their only treatment and 26% received no therapy at all, compared to 13% and 15% of white patients, respectively.

Surgery is the most common form of treatment for esophageal cancer. Although the disease typically has a poor prognosis, almost 20% of patients with locoregional esophageal cancer survive at least five years after surgery. In 2004, approximately 14,250 new cases of esophageal cancer were diagnosed in the United States, and an estimated 13,300 people died of the disease. Esophageal cancer is nearly three times more common among men than women, and three times more prevalent among blacks than whites. The overall five-year relative survival rate of people with esophageal cancer is 14%.

Researchers at the Dana Farber Cancer Institute in Boston reviewed the Medicare records of 2,946 non-Hispanic white patients and 367 African-American patients from the SEER database with locoregional esophageal cancer ages 65 and older. Patients were classified by sex, age at diagnosis, geographic region, socioeconomic status, and pre-existing health conditions. In comparison to white patients, African-American patients were slightly younger, had a lower socioeconomic status, and had more pre-existing diseases, such as heart disease and diabetes. African-American patients were also more likely to have squamous cell cancer, which typically arises in the middle or upper part of the esophagus.

To better understand why blacks are less likely to undergo surgery, researchers examined the proportion of black and white patients ever assessed by a surgeon, and the rate of surgery among those receiving a surgical evaluation. They found that 70% of African-American patients were assessed by a surgeon, compared to 78% of white patients. Among the 258 African-American patients who received a surgical evaluation, only 35% underwent surgery, compared to 59% of 2,307 white patients. Researchers noted that age, socioeconomic status, and pre-existing health conditions only partly explained why black patients experienced a lower rate of surgical evaluation and surgery.

African Americans also exhibited poorer survival rates at every stage of follow-up compared to white patients. Two years after diagnosis, 18% of African Americans were still alive, compared to 25% for white patients. However, when African Americans received surgery, they experienced similar survival rates to white patients receiving surgery.

"African-American patients need equal opportunities to receive quality cancer care. The time has come for us to move beyond just trying to remove barriers to access to care and actually work to engage vulnerable patients and find ways to facilitate their participation in care," Dr. Steyerberg said.

Researchers added that they were limited by the observational nature of the study, noting that SEER data could not completely explain racial disparities in treatment, particularly the role of patient preference and physician bias.

"Racial Differences in Surgical Evaluation, Treatment, and Outcome of Locoregional Esophageal Cancer: A Population-based Analysis of Elderly Patients." Ewout W. Steyerberg, et al, Center for Clinical Decision Sciences, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.