Poor blacks at higher risk of dying after esophageal cancer surgery

Last Updated: 2016-01-29

By Megan Brooks

NEW YORK (Reuters Health) - Prior studies have suggested that black patients have worse survival after esophagectomy, but a new study finds that racial disparities are impacted by socioeconomic status (SES).

Only black patients with lower SES seem to have worse survival, the study suggests.

"Black and white patients in higher SES quartiles have no statistically significant difference in mortality after esophageal cancer surgery," Dr. Loretta Erhunmwunsee reported at a January 26 briefing at The Society of Thoracic Surgeons annual meeting in Phoenix, Arizona. Dr. Erhunmwunsee led the study while at Duke Health in Durham, North Carolina, and is now with City of Hope in Duarte, California.

Using the National Cancer Data Base, Dr. Erhunmwunsee and colleagues identified more than 16,800 patients with localized stage I-III esophageal cancer, of whom 6,147 underwent esophagectomy between 2003 and 2011.

Black patients made up 5% (n=293) of those who had surgery, and 40% (n=2,476) of patients were in the lowest two income quartiles. SES was defined using the average income of the households in the area (zip code) where the patient lived at the time of diagnosis.

"Consistent with the rest of the literature," Dr. Erhunmwunsee reported, "blacks had worse overall survival than whites," with a median overall survival (OS) of 33 vs. 46 months (p=0.002).

"We also found that when you compared all of the income groups, there was an increase in survival with each increasing income quartile. The poorest patients had the worst survival and the wealthiest patients had the best survival," she noted. Median OS was 57 months for Q4 (highest income), compared to 46, 43 and 33 months, respectively, for Q3, Q2 and Q1 (p<0.001).

In further analysis, they found that being black and in a lower income group remained significantly associated with worse overall survival. Median OS for blacks in Q1-Q2 was 26 months, compared to 40 months for whites in Q1-Q2. But there was no difference in survival among blacks and whites in the highest two income groups (61 and 52 months for blacks and whites, respectively), Dr. Erhunmwunsee reported.

Race was "not important" in terms of survival in the high income quartiles, she said. "Not surprisingly, older age and more advanced stage were associated with worse survival in both the lower and upper income groups."

A limitation of the study is the small number of black patients who underwent surgery and who were in the upper income quartile.

"These results show that poorer patients are at a higher risk of death following surgery," Dr. Erhunmwunsee said in a conference statement. "This disparity likely is based on many factors - minority patients and patients with lower socioeconomic status often smoke more, have poor eating habits, exercise less, and are exposed to environmental hazards, all of which lead to worse health. And specifically, increased smoking and poorer eating habits can increase the risk of esophageal cancer."

She added, "Prior studies have shown that ethnic minority and poor patients who have access to care may still get inappropriate treatment; however, even when they do receive adequate therapy (surgery), as in this study, disparities are prevalent. These finding are important to patients because being aware of the factors that are linked to higher death rates can empower patients to be more active with their own health and medical care."

She added, "We also hope that awareness of the problem among physicians and patients alike will lead to more public and professional focus on solving this disparity through strategies aimed at health policy, practices of health systems, and training of health care providers."