Outcome of Esophageal Carcinoma in the Veteran Affairs Population A Comparative Analysis From the Veteran Affairs Central Cancer Registry
ABSTRACT Reports indicate that esophageal carcinoma is changing with a shift from squamous cell carcinoma (SCC) to adenocarcinoma (AC) along with worse survival in black patients. However, data on esophageal carcinoma in the Veteran Affairs (VA) population is lacking. We set to describe site-specific and histology-specific characteristics of esophageal cancer in the VA population over the past decades.
We queried the VA Central Cancer Registry database for esophageal cancer cases between 1995 and 2005. Patient characteristics and treatment methods were obtained and overall survival was estimated using the Kaplan-Meier method.
There were 7929 patients included in the study. The median survival in the period 1995 to 1999 was 7.53 months and 2000 to 2005 was 8.33 months. The median survival in AC was 8.93 months; SCC was 7.30 months. Cox-regression multivariate model revealed that location, age, histology, stage, and treatment were independent predictors of survival. Blacks were less likely to undergo surgery and more likely to undergo radiation.
In nonmetastatic esophageal cancer at the VA, SCC has worse outcome as compared with AC. Blacks with AC have worse outcome than whites. Despite equal access to health care blacks are less likely to undergo surgery, which may contribute to their worse outcome. We recommend further studies to determine factors leading to selection of treatment modalities in minority patients.
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ABSTRACT: Blacks have a higher mortality rate than whites from esophageal cancer, but the reasons underlying this disparity remain unclear. In this study, we used a national sample of patients with resectable esophageal cancer to assess the extent to which racial inequalities in care can explain outcome disparities. We identified all non-Hispanic white and black patients diagnosed with T0-T2, node-negative esophageal cancer between 1988 and 2003 from the Surveillance, Epidemiology, and End Results registry. Racial differences in esophageal-specific survival were assessed using the Kaplan-Meier method. We performed Cox regression to test for racial differences in survival after adjusting for potential confounders and to assess the extent to which disparities can be explained by later diagnosis or treatment inequalities. A total of 1522 patients were included in the study. Blacks had worse esophageal-specific survival rates than whites (37% vs 60% 5-year survival; P < .0001). Blacks were more likely to be diagnosed at a more advanced stage and to have squamous cell tumors, but were less likely to undergo surgery. In multivariate regression controlling for age, sex, marital status, histology, and tumor location, black race was associated with worse survival. When tumor status, surgery, and radiotherapy were added to the model, race was no longer significantly associated with survival. These data suggest that blacks are at greater risk of death from esophageal cancer. While the disparity is due in part to differences in tumor histology, diagnosis at an earlier stage and higher rates of surgery among blacks could reduce this survival disparity.Annals of Surgical Oncology 03/2008; 15(3):881-8. DOI:10.1245/s10434-007-9664-5 · 3.94 Impact Factor
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ABSTRACT: The incidence and mortality related to esophageal adenocarcinoma (EAC) has been rising in the United States. Meanwhile, the number of diagnostic and therapeutic procedures has increased in number and improved technologically. However, the impact of these advances on the survival of EAC in clinical practice remains unknown. Patients with histologically proven EAC between 1973 and 1997 were identified in registries of the Surveillance, Epidemiology, and End Results database, and analyzed in 5-yr time periods. The observed and relative survival rates were calculated. The joint influence of the time of diagnosis, stage and grade of cancer, demographic features, surgical therapy, and radiotherapy were assessed in Cox proportional hazard survival analyses. Between 1973 and 1997, we identified 4835 patients with EAC. The 1-yr and 5-yr observed survival rates increased from 34% and 5% during 1973-1977 to 44% and 13% during 1993-1997 (p < 0.05). In the Cox survival analysis, the more recent year of diagnosis, early stage of tumor, younger age at presentation, receiving radiotherapy or surgery were independent predictors of reduced risk of mortality. The proportion of patients with in situ EAC and those with local spread increased progressively from 0.3% and 17.7% in 1973-1977 to 2.3% and 25.3%, respectively, in 1993-1997 (p < 0.05). The proportion of patients receiving radiation therapy either before or after surgery has increased from 7% in 1973-1977 to 16% in 1993-1997 (p < 0.05). The short- and long-term survival of patients with EAC has improved slightly in the United States over the past 25 yr. Some of the improvement may be related to an increase in the number of younger patients, and in cases with in situ and localized cancers. However, the overall survival of patients with EAC remains dismal.The American Journal of Gastroenterology 07/2003; 98(7):1627-33. DOI:10.1111/j.1572-0241.2003.07454.x · 9.21 Impact Factor
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ABSTRACT: Reports of dramatic increases in gastric cardia cancer incidence warrant concern. However, the recent introduction of a separate diagnostic code, the lack of a consensus definition of the cardia area, and the accelerating interest in cardia cancer may affect classification practices. Little is known about the magnitude of cardia cancer misclassification in large cancer registries. In a well-defined Swedish population (1.3 million), we uniformly classified all patients with newly diagnosed gastric adenocarcinoma (from 1989 through 1994) with respect to gastric subsite, and we used this patient group as our gold standard. We then evaluated the completeness of the Swedish Cancer Registry in registering gastric adenocarcinomas against this gold standard and, further, assessed the completeness of cardia cancer registration and the rate of falsely included cases to estimate the potential impact on observed incidence trends. Our gold standard contained 1337 case subjects with gastric adenocarcinoma. Overall, the Swedish Cancer Registry was 98% complete with regard to gastric adenocarcinomas and had a 4% rate of falsely included cases. The completeness of coding cardia cancer was only 69%, and the positive predictive value for cardia cancer was 82%, with no improvement over time. Although overall completeness of gastric cancer registration by the Swedish Cancer Registry was excellent, accuracy in registering cardia tumors was surprisingly low. Our estimates suggest that true cardia cancer incidence could be up to 45% higher or 15% lower than that reported in the Cancer Registry. This margin of error could accommodate the observed increase in cardia cancer in Sweden. Therefore, secular trends in cardia cancer incidence should be interpreted cautiously.JNCI Journal of the National Cancer Institute 06/1999; 91(9):786-90. DOI:10.1093/jnci/91.9.786 · 15.16 Impact Factor