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Esophageal Cancer Treatment Is Underutilized Among the Elderly in the United States
Daniela Molena*2, Miloslawa Stem1, Anne O. Lidor3
1Johns Hopkins Medicine, Baltimore, MD; 2Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; 3Surgery, University of Wisconsin-Madison, Madison, WI
Objectives: Multimodality treatment has been shown to increase survival in patients with locally advanced esophageal cancer without increasing morbidity. Despite this, a large number of elderly patients in the United States do not receive any treatment at all following the diagnosis of esophageal cancer. Although the exact reasons for this are unknown, a potential explanation could be due to concerns that elderly patients would not tolerate a more aggressive approach. We sought to characterize factors contributing to the lack of treatment received in this group.
Methods: Patients ≥ 65 years diagnosed with regional esophageal cancer between 2001 and 2009 were identified from the Surveillance Epidemiology and End Results (SEER)-Medicare linked database. Treatment was defined as receiving any medical or surgical therapy for esophageal cancer. Logistic regression analysis was used to identify factors associated with failure to receive treatment. Overall five-year survival was analyzed using the Kaplan-Meier method.
Results: 5072 esophageal cancer patients (median age 75 years, IQR 71-81) were included in the study. The majority of patients were white (91%), males (79%), with adenocarcinoma on histology (91%). 38% (n=1933) of patients did not receive any treatment for their cancer. Among the treated patients, 76% (n=2387) never underwent surgery as part of their management. Several demographic factors as well as some socioeconomic characteristics (including non-married status and lower education) (Table) were associated with lack of treatment on multivariable analysis. Patients who received therapy had a better overall survival (log-rank, p<0.001) (Figure), with a median 5-year survival of 11.7 months among treated patients compared to 7.7 months among non-treated patients.
Conclusions:
Elderly patients with locally advanced cancer of the esophagus have improved five-year survival when undergoing treatment for their cancer. The overall survival however is very low even in the treated patients, possibly due to the small number of patients undergoing surgery as part of their care plan. Disparities in the utilization of treatment for potentially curable cancers are associated with regional and socioeconomic factors, and not the presence of comorbidities.
Factors associated with lack of treatment for regional esophageal cancer in the elderly, SEER-Medicare 2001-2009
| Factor | OR (95% CI) | p | SEER region
NE
MW
S
W | -
Reference
3.19 (2.34-4.36)
5.26 (3.95-7.01)
6.52 (5.17-8.21) | -
-
<0.001
<0.001
<0.001 | Age, y
65-69
70-74
75-79
≥80 | -
Reference
1.12 (0.89-1.41)
1.43 (1.13-1.80)
2.34 (1.86-2.95) | -
-
0.350
0.003
<0.001 | | Male | 0.81 (0.67-0.97) | 0.026 | Race
White
Black
Other | -
Reference
1.26 (0.88-1.79)
1.02 (0.74-1.40) | -
-
0.197
0.916 | Marital status
Married
Single (never married)
Divorced
Widowed | -
Reference
1.35 (1.02-1.81)
1.15 (0.86-1.53)
1.33 (1.09-1.63) | -
-
0.039
0.355
0.005 | At least 12 yrs of education
Q4
Q3
Q2
Q1 (lowest) | -
Reference
1.10 (0.88-1.38)
1.43 (1.12-1.84)
1.42 (1.08-1.88) | -
-
0.413
0.004
0.014 | Histology
Adenocarcinoma
Squamous cell carcinoma | -
Reference
0.94 (0.72-1.25) | -
0.685 |
SEER, Surveillance, Epidemiology, and End Results; OR, Odd Ratio; CI, Confidence Interval. Other race: Asian, Hispanic and Native American. Logistic regression model adjusted for year, SEER region, age, sex, race, marital status, income, education, Charlson Index, Barrett's Esophagus, histology, tumor location, and differentiation. 
Figure. Kaplan-Meier curves of five-year overall survival rates for older regional esophageal cancer patients who received treatment versus those who received none.
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