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Treatment and Survival Disparities of Locoregional Gastroesophageal Cancer in Whites, Blacks and Asian Americans: a SEER-Database Analysis
Xi E. Zheng^*, Xi Kathy Zhou
Public Health, Weill Cornell Medical College, New York, NY

Background: Cancers that arise from the lower esophagus, esophagogastric junction and gastric cardia, so-called gastroesophageal cancers (GEC), predominantly adenocarcinomas, have trended up rapidly in incidence since the mid-1970s. Despite advances in multimodal therapies for GEC, the overall survival remains poor. African Americans have known worse outcome of GEC, however the reasons are still elusive. Studies on the outcome of GEC in the Asian Americans are sparse. Methods: In this study, we examined the racial differences in receipt of surgery and survival of locoregional GEC among whites, blacks and Asian Americans, using the latest Surveillance Epidemiology and End Results database. Subjects diagnosed with a primary GEC between 1998 and 2010 were extracted along with their demographics, tumor- and therapy-related variables. Multivariate logistic regression, Kaplan-Meier and Cox proportional hazards regression analyses were performed to identify the factors influencing the receipt of surgery and cancer-specific survival using STATA. Results: 12,543 patients, diagnosed with primary GEC, consisting of 11,043 whites, 830 blacks and 526 Asian Americans were included. The Asian Americans had a similar surgical rate as the whites, while the black patients had lower surgical rate than whites [59% vs 80%; OR=0.53; p<0.001], after controlling for all potential covariates. Specifically, blacks had 39% lower rate of local tumor excision, 32% less partial esophagectomy or gastrectomy, and 62% less total esophagectomy/gastrectomy compared to whites (p<0.05). Additionally, blacks were 2-fold more likely to refuse recommended surgery, and to have unknown or undocumented reasons for not receiving recommended surgery than whites (p < 0.001). The median survivals were 19, 33 and 35 months for blacks, whites and Asian Americans, respectively. Being black was associated with a HR of 1.41 for cancer-specific mortality of GEC compared to white (p < 0.001). After controlling for patient and tumor characteristics, the HR for black vs white was 1.20 (p < 0.001); further adjustment for surgery reduced the difference in hazards to a statistically insignificant value (HR=1.11, p=0.06). Surgery reduced HR of cancers at the midesophagus and lower more pronouncedly than at the cardia for blacks vs whites. In contrast, there was no difference in the survival of GEC between Asian Americans and whites. Conclusions: Blacks had markedly lower rate of surgical intervention and worse survival of locoregional GEC than whites and Asian Americans. The black-white survival differences were more profound for cancers of the mid- or lower esophagus than that of the cardia. Surgery diminished the survival disadvantages in blacks. More efforts are needed to promote patient education, surgeon-patient communication and close follow up for black patients to improve their survival of GEC.

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