black patients die earlier after surgery for esophageal cancer andrea s. wolf, md, mph, emanuela...
TRANSCRIPT
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Black Patients Die Earlier after Surgery for Esophageal Cancer
Andrea S. Wolf, MD, MPH, Emanuela Taioli MD, PhD,
Marlene Camacho-Rivera, ScD, MPH, Andrew Kaufman, MD,
Dong-Seok Lee, MD, Faiz Bhora, MD, Raja M. Flores, MD
Department of Thoracic SurgeryThe Icahn School of Medicine at Mount Sinai
The Mount Sinai Health System New York, NY
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No financial disclosures
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Introduction
• Esophageal cancer in black patients
Higher incidence and mortalityHigher rate of squamous cell CALower use of surgeryWhen adjusted for surgery, no
difference in survival
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Objective
• To determine whether race affects short and long-term mortality in patients having surgery for esophageal cancer using SEER
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Methods
• SEER 1973-2011
• Inclusion:• Blacks, Whites• Adenocarcinoma, SCC
• Exclusion:• Distant metastases• Cervical esophageal CA
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Methods
• Cox proportional hazards model
• Outcome: Overall survival
• Predictors: • Race• Age• Sex• Year of dx• Stage• Cancer-directed surgery• Radiation
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Baseline characteristicsVariable Categories Whites
(n = 13,678)Blacks
(n = 2,894)
p-value
Sex Male 10,168 (74%) 2,079 (72%) 0.005
Female 3,510 (26%) 815 (28%)
Mean age in yr (95% CI) 67.8 (67.6-68.0) 61.6 (61.2-61.9) <0.0001
Overall Stage
Localized 6,609 (48%) 1,508 (52%) <0.0001
Regional 7,069 (52%) 1,386 (48%)
Histology
SCC 6,775 (50%) 2,777 (96%) <0.0001Adenocarcinoma 6,903 (50%) 117 (4%)
Cancer-directed surgery
No 6,428 (47%) 1,726 (60%) <0.0001
Yes 7,250 (53%) 1,168 (40%)
Radiation
No 4,960 (36%) 935 (32%) <0.0001
Yes 8,476 (62%) 1,870 (65%)
Unknown 242 (2%) 89 (3%)
Therapy
None 1,619 (12%) 411 (14%) <0.0001
Surgery only 3,341 (25%) 524 (19%)
Radiation only 4,678 (35%) 1,258 (45%)
Both surgery and radiation
3,798 (28%) 612 (22%)
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Incidence over time
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Cox model 1-year mortality Overall SCC AC
Variable Adjusted HR (95% CI)
Race Black versus White 1.24 (1.16-1.32) 1.21 (1.13-1.30) 1.06 (0.77-1.45)
Sex Female versus Male 0.95 (0.90-1.01) 0.94 (0.88-1.00) 0.97 (0.86-1.09)
Age Per increased year 1.02 (1.01-1.02) 1.01(1.01-1.02) 1.02 (1.02-1.02)
Stage Regional versus Localized
1.60 (1.53-1.69) 1.48 (1.39-1.58) 1.78 (1.63-1.94)
Histology SCC versus AC 1.22 (1.15-1.30) -- --
Therapy None 1.0 (REF) 1.0 (REF) 1.0 (REF)
Surgery only 0.30 (0.27-0.33) 0.31 (0.28-0.35) 0.27 (0.24-0.31)
Radiation only 0.56 (0.52-0.60) 0.53 (0.48-0.58) 0.63 (0.56-0.72)
Both surgery and radiation
0.34 (0.31-0.37) 0.36 (0.32-0.40) 0.30 (0.26-0.35)
Year of Diagnosis
Per increased year 0.97 (0.97-0.97) 0.97 (0.97-0.98) 0.96 (0.96-0.97)
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Cox model 1-year mortality
Overall SCC AC
Variable Adjusted HR (95% CI)
Race Black versus White
1.24 (1.16-1.32) 1.21 (1.13-1.30) 1.06 (0.77-1.45)
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Cox model 1-year mortality
Overall SCC AC
Variable Adjusted HR (95% CI)
Stage Regional versus Localized
1.60 (1.53-1.69) 1.48 (1.39-1.58) 1.78 (1.63-1.94)
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Cox model 1-year mortality
Overall SCC AC
Variable Adjusted HR (95% CI)
Histology SCC versus AC
1.22 (1.15-1.30) -- --
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Cox model 1-year mortality
Overall SCC AC
Variable Adjusted HR (95% CI)
Therapy None 1.0 (REF) 1.0 (REF) 1.0 (REF)
Surgery only 0.30 (0.27-0.33) 0.31 (0.28-0.35) 0.27 (0.24-0.31)
Radiation only 0.56 (0.52-0.60) 0.53 (0.48-0.58) 0.63 (0.56-0.72)
Both surgery and radiation
0.34 (0.31-0.37) 0.36 (0.32-0.40) 0.30 (0.26-0.35)
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Localized esophageal cancer
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Treated with surgery
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Without treatment
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Localized esophageal cancer
Surgery No treatment
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Treated with surgery
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Conclusions
• Black race is independently associated with higher mortality in esophageal cancer
• Black patients treated with surgery have poorer survival than Whites
• Racial difference in mortality most pronounced at first year
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Future directions
• Differences in how black and white patients are being selected for surgery?
• Racial disparities in access to dedicated thoracic surgeons doing safe esophagectomies at high volume centers?
• Disparities in treatment at cancer centers with coordinated multi-disciplinary care?
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Baseline CharacteristicsVariable Categories Whites
(n = 13,678)Blacks
(n = 2,894)
p-value
Sex Male 10,168 (74%) 2,079 (72%) 0.005
Female 3,510 (26%) 815 (28%)
Mean age in yr (95% CI) 67.8 (67.6-68.0) 61.6 (61.2-61.9) <0.0001
Overall Stage
Localized 6,609 (48%) 1,508 (52%) <0.0001
Regional 7,069 (52%) 1,386 (48%)
Histology
SCC 6,775 (50%) 2,777 (96%) <0.0001Adenocarcinoma 6,903 (50%) 117 (4%)
Cancer-directed surgery
No 6,428 (47%) 1,726 (60%) <0.0001
Yes 7,250 (53%) 1,168 (40%)
Radiation
No 4,960 (36%) 935 (32%) <0.0001
Yes 8,476 (62%) 1,870 (65%)
Unknown 242 (2%) 89 (3%)
Therapy
None 1,619 (12%) 411 (14%) <0.0001
Surgery only 3,341 (25%) 524 (19%)
Radiation only 4,678 (35%) 1,258 (45%)
Both surgery and radiation
3,798 (28%) 612 (22%)
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Cox model 1-year mortality Overall SCC AC
Variable Adjusted HR (95% CI)*
Race Black versus White 1.24 (1.16-1.32) 1.21 (1.13-1.30) 1.06 (0.77-1.45)
Sex Female versus Male 0.95 (0.90-1.01) 0.94 (0.88-1.00) 0.97 (0.86-1.09)
Age Per increased year 1.02 (1.01-1.02) 1.01(1.01-1.02) 1.02 (1.02-1.02)
Stage Regional versus Localized 1.60 (1.53-1.69) 1.48 (1.39-1.58) 1.78 (1.63-1.94)
Histology SCC versus AC 1.22 (1.15-1.30) -- --
Therapy None 1.0 (REF) 1.0 (REF) 1.0 (REF)
Surgery only 0.30 (0.27-0.33) 0.31 (0.28-0.35) 0.27 (0.24-0.31)
Radiation only 0.56 (0.52-0.60) 0.53 (0.48-0.58) 0.63 (0.56-0.72)
Both surgery and radiation 0.34 (0.31-0.37) 0.36 (0.32-0.40) 0.30 (0.26-0.35)
Year of Diagnosis
Per increased year 0.97 (0.97-0.97) 0.97 (0.97-0.98) 0.96 (0.96-0.97)
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Cox model 3-year mortality Overall SCC AC
Variable Adjusted HR (95% CI)*
Race Black versus White 1.24 (1.17-1.30) 1.22 (1.15-1.29) 1.09 (0.86-1.39)
Sex Female versus Male 0.94 (0.89-0.98) 0.91 (0.87-0.96) 0.98 (0.90-1.07)
Age Per increased year 1.01 (1.01-1.02) 1.01(1.01-1.02) 1.02 (1.01-1.02)
Stage Regional versus Localized 1.67 (1.60-1.73) 1.47 (1.40-1.55) 1.90 (1.78-2.03)
Histology SCC versus AC 1.15 (1.10-1.21) -- --
Therapy None 1.0 (REF) 1.0 (REF) 1.0 (REF)
Surgery only 0.33 (0.31-0.36) 0.37 (0.33-0.41) 0.29 (0.26-0.33)
Radiation only 0.64 (0.60-0.68) 0.59 (0.54-0.64) 0.74 (0.66-0.82)
Both surgery and radiation 0.42 (0.39-0.45) 0.42(0.38-0.46) 0.41 (0.37-0.46)
Year of Diagnosis
Per increased year 0.97 (0.97-0.97) 0.97 (0.97-0.98) 0.96 (0.96-0.96)
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Cox model overall mortality Overall SCC AC
Variable Adjusted HR (95% CI)*
Race Black versus White 1.25 (1.19-1.31) 1.23 (1.17-1.29) 1.04 (0.83-1.30)
Sex Female versus Male 0.91 (0.88-0.95) 0.89 (0.85-0.94) 0.98 (0.90-1.06)
Age Per increased year 1.02 (1.01-1.02) 1.01(1.01-1.02) 1.02 (1.02-1.03)
Stage Regional versus Localized 1.60 (1.55-1.66) 1.44 (1.38-1.51) 1.78 (1.68-1.89)
Histology SCC versus AC 1.13 (1.09-1.18) -- --
Therapy None 1.0 (REF) 1.0 (REF) 1.0 (REF)
Surgery only 0.37 (0.34-0.39) 0.40 (0.36-0.44) 0.33 (0.30-0.37)
Radiation only 0.69 (0.65-0.74) 0.64 (0.59-0.70) 0.79 (0.71-0.87)
Both surgery and radiation
0.47 (0.44-0.50) 0.47(0.43-0.51) 0.47 (0.42-0.52)
Year of Diagnosis
Per increased year 0.97 (0.97-0.97) 0.98 (0.97-0.98) 0.96 (0.96-0.96)