E. C. Sturm3, W. E. Zahnd3, J. D. Mellinger3, S. Ganai3 1Southern Illinois University,Department Of Surgery,Springfield, IL, USA 2Southern Illinois University,Center For Clinical Research,Springfield, IL, USA 3Southern Illinois University School Of Medicine,Department Of Surgery,Springfield, IL, USA
Introduction:
Despite high morbidity after esophagectomy, improvements in perioperative management and preoperative staging have led to satisfactory outcomes at high-volume centers. While management of early-stage cancers have recently transitioned to include endoscopic interventions for T1a and induction chemotherapy for high-risk T2 adenocarcinomas, esophagectomy has been the mainstay of management of early-stage (I-IIA) esophageal cancer. This study examines whether or not patients with early-stage, resectable cancers are being offered surgery.
Methods:
A retrospective cohort study was conducted on resectable esophagus cancer cases in the National Cancer Database diagnosed between 1998 and 2012, including AJCC clinical T1 or T2 patients with no lymph node or metastatic involvement. We determined frequencies and percentages to describe the demographic characteristics of patients. We also categorized patients by surgical decision: had surgery and reasons why if they did not have surgery (not offered, refused, comorbidities or advanced age, unknown or died before surgery). We performed a chi-square trend test to determine trends in surgery and reasons for no surgery over time. We performed chi square analysis to compare surgery decisions by demographic characteristics.
Results:
A total of 22,994 patients with T1 or T2 esophageal cancer were identified. 10,150 (44%) had surgery while 12,844 (56%) did not have surgery. Of those who did not undergo surgery, reasons given included advanced age or comorbidities (5.8%), refused (2.5%), unknown or died before surgery (6.7%), or that surgery was not offered to the patient (40.9%). The proportion of patients who had surgery increased from 33% in 1998 to 50% in 2012 while the proportion who were not offered surgery decreased from 44% to 38% (p<0.001). Surgical decision varied significantly by demographic characteristics. Patients who were women, older, non-white minorities (especially blacks), uninsured or Medicaid insurance status, not treated at an academic center, less educated, and low income were all significantly associated with lower rates of surgery (p<0.001).
Conclusion:
A large proportion of patients with potentially resectable esophageal cancer are not being offered surgery. This percentage has decreased over time but is still unacceptably high. Disparities exist in types of patients who are offered surgery. Further study on surgical access disparities in esophageal cancer are warranted.
