JA Dominitz, MD, MHS, VA Puget Sound Health Care System, University of Washington, Seattle, WA; C Maynard, PhD, VA Puget Sound Health Care System, University of Washington, Seattle, WA; KG Billingsley, MD, VA Puget Sound Health Care System, University of Washington, Seattle, WA; EJ Boyko, MD, MPH, VA Puget Sound Health Care System, University of Washington, Seattle, WA

Objectives: Prior studies have found racial differences in cancer treatment and survival. The purpose of this study was to assess the influence of race on the treatment and survival of patients with distal esophageal cancer.

Methods: All black and white male veterans hospitalized at any VA medical center with a diagnosis of distal esophageal cancer during fiscal years 1993-1997 were identified. Those veterans with a personal history of esophageal cancer or hospitalized in 1992 with esophageal cancer were excluded. Using inpatient and outpatient administrative databases, we determined the utilization of surgical resection, chemotherapy, radiation therapy and mortality. Other measured variables included comorbidity, age, presence of metastases, eligibility status, and marital status. Multiple logistic regression was used to determine the association between race and treatment with adjustment for the other measured variables. Cox proportional-hazards models were used to compare mortality. Separate models were created for adenocarcinoma and squamous cell carcinoma (SCC).

Results: 1290 white and 231 black male veterans with a new diagnosis of distal esophageal cancer were identified. Among veterans with adenocarcinoma, surgery was performed in 23% of black and 36% of white veterans (p<0.025). There were no significant differences in the utilization of radiation therapy (32% vs. 27%) or chemotherapy (40% vs. 34%) for black and white veterans, respectively. Among veterans with SCC, surgery was performed in 19% of black and 35% of white veterans (p<0.001). Unlike veterans with adenocarcinoma, black veterans with SCC were significantly more likely than white veterans to receive radiation therapy (51% vs. 37% respectively, p<0.01) and chemotherapy (48% vs. 37% respectively, p<0.025). Adjusting for potential confounders, black veterans with esophageal adenocarcinoma were less likely to undergo surgery (adjusted odds ratio (OR) 0.56, 95% confidence interval (CI) 0.32-0.99) but had similar odds of undergoing chemotherapy and radiation therapy. Black veterans with SCC were less likely to undergo surgical resection (OR 0.40, 95% CI 0.26-0.62), but were more likely to undergo radiation therapy (OR 1.62, 95% CI 1.14-2.30) and chemotherapy (OR 1.45, 95% CI 1.01-2.08). Among veterans with adenocarcinoma, the median survival was 237 days for black veterans and 201 days for white veterans (p=0.91). Among veterans with SCC, the median survival was 148 days for black veterans and 248 days for white veterans (p=0.0006, log-rank test). Using Cox proportional hazards models, mortality was increased for black veterans with SCC (adjusted risk ratio 1.41, 95% CI 1.17-1.70) but not adenocarcinoma. Among the subset of veterans who underwent surgical resection (n=502), similar mortality results were found.

Conclusions: Black veterans with distal SCC are less likely than white veterans to undergo surgical resection, while the use of radiation therapy and chemotherapy, as well as mortality, is increased. Black veterans with distal esophageal adenocarcinoma have lower odds of undergoing surgical resection but have similar utilization of radiation therapy and chemotherapy and similar survival.

Impact: Despite the presence of an equal access medical system, treatment and outcomes differ for black and white veterans with distal esophageal cancer. This study demonstrates the need to improve our understanding of racial differences in health care and outcomes.