A narrative review of socioeconomic disparities in the treatment of esophageal cancer

Is There Bias in the Assessment of Contraindications for Resection? Disparities in the Surgical Management of Early-Stage Esophageal Cancer

BACKGROUND

Resection is considered the standard of care for patients with localized esophageal cancer who are "physiologically fit". Patients who do not meet this standard are considered contraindicated to receive surgery. We hypothesized that among patients with non-metastatic esophageal cancer, the consideration of contraindication status would vary based on clinical and demographic factors and would vary between institutions.

METHODS

We identified patients with non-metastatic gastric and esophageal cancer in the National Cancer Database (NCDB) from 2004 to 2018. Patients were categorized into three groups based on surgical treatment: surgical resection (including endoscopic mucosal resection), resection contraindicated, and refusal of resection based on the coding of the "reason for no surgery" data element. Demographic, clinical, and institutional characteristics were compared between the groups using bivariate and multivariate techniques to identify factors associated with contraindicated status. A subgroup analysis of cT1N0M0 patients was also used to assess every institution in the NCDB's observed-expected ratio for contraindication status.

RESULTS

In total, 144,591 patients with non-metastatic disease met inclusion criteria: 124,972 (86%) underwent resection, 13,793 (10%) were contraindicated for resection, and 5826 (4%) refused resection. Contraindication was associated with age, non-Hispanic Black race, socioeconomic status, Charlson-Deyo score, insurance type, institution characteristics, clinical T-stage, and clinical N-stage. There were 9459 patients who were cT1N0M0 and had no co-morbidities. In this cohort, there were more than 1000-fold differences between individual programs regarding observed-expected ratio of contraindication status when adjusting for clinical and demographic characteristics.

CONCLUSIONS

Variation in the assessment of contraindication status varies dramatically between institutions. Underserved minorities, including age, race, and insurance type, are risk factors for being considered contraindicated. These findings highlight the disparities that exist regarding surgical care of non-metastatic esophageal cancer in the United States.

Global Burden of Esophageal Cancer and Its Risk Factors: A Systematic Analysis of the Global Burden of Disease Study 2019

BACKGROUND

Esophageal cancer is a major public health issue, yet risk factors for its occurrence are still insufficiently known. This study aimed to estimate the global burden of esophageal cancer and its risk factors.

METHODS

This ecological study presented the incidence, mortality, and Disability-Adjusted Life Years (DALYs) of esophageal cancer in the world. This study collected the Global Burden of Disease study data from 1990 to 2019. Trends in esophageal cancer burden were assessed using the joinpoint regression analysis and calculating the average annual percent change (AAPC).

RESULTS

Globally, in 2019, in both sexes and all ages, the ASR for the incidence of esophageal cancer was 6.5 per 100,000 and for mortality, 6.1 per 100,000. The global proportion of DALYs for esophageal cancer attributable to selected behavioral, metabolic, and dietary risk factors was similar in males and females: chewing tobacco (3.8% vs. 5.1%), diet low in fruits (10.1% vs. 12.6%), diet low in vegetables (3.3% vs. 4.6%), and high body mass index (18.8% vs. 19.3%). However, the proportion of DALYs for esophageal cancer attributable to smoking and alcohol use was 4-5 times higher in males than in females (50.1% vs. 11.3%, and 29.6% vs. 5.1%, respectively). From 1990 to 2019, a significant decrease in global trends in rates of DALYs for esophageal cancer attributable to smoking (AAPC = -1.6%), chewing tobacco (AAPC = -0.5%), alcohol use (AAPC = -1.0%), a diet low in fruits (AAPC = -3.1%), and a diet low in vegetables (AAPC = -3.6%) was observed, while a significant increase in trends was observed in DALYs rates for esophageal cancer attributable to a high body mass index (AAPC = +0.4%).

CONCLUSIONS

More epidemiological research is needed to elucidate the relationship between esophageal cancer and certain risk factors and guide prevention efforts.

Synthesis of Amphiphilic Amino Poly-Amido-Saccharide and Poly(lactic) Acid Block Copolymers and Fabrication of Paclitaxel-Loaded Mucoadhesive Nanoparticles

Drug delivery to the esophagus through systemic administration remains challenging, as minimal drug reaches the desired target. Local delivery offers the potential for improved efficacy while minimizing off-target toxicities but necessitates bioadhesive properties for mucosal delivery. Herein, we describe the synthesis of two new mucoadhesive amphiphilic copolymers prepared by sequential ring-opening copolymerization or postpolymerization click conjugation. Both strategies yield block copolymers containing a hydrophilic amine-functionalized poly-amido-saccharide and either a hydrophobic alkyl derivatized poly-amido-saccharide or poly(lactic acid), respectively. The latter resulting copolymers readily self-assemble into spherical, ≈200 nm diameter, positively charged mucoadhesive nanoparticles. The NPs entrap ultrahigh levels of paclitaxel via encapsulation of free paclitaxel and paclitaxel conjugated to a biodegradable, biocompatible poly(1,2-glycerol carbonate). Paclitaxel-loaded NPs rapidly enter cells, release paclitaxel, are cytotoxic to esophageal OE33 and OE19 tumor cells in vitro, and, importantly, demonstrate improved mucoadhesion compared to conventional poly(ethylene glycol)-poly(lactic acid) nanoparticles to ex vivo esophageal tissue.

Current findings on the antitumor effects of metformin on esophageal squamous cell carcinoma (Review)

Esophageal squamous cell carcinoma (ESCC) is an intractable type of cancer that requires novel therapeutic modalities, since the therapeutic outcomes are often inadequate, even in response to multidisciplinary treatment. The antitumor effect of metformin, an antidiabetic drug, has been reported in esophageal cancer; however, its effects are diverse. Since various multidisciplinary therapies are used in ESCC, the antitumor effect of metformin is expected to be synergistic in some treatment strategies. The present review summarizes the antitumor effects of metformin and discusses its use in combination with existing therapies. The present study reviewed relevant studies where the molecular targets of metformin (AMPK and inflammatory system signals) were described, followed by the classification and organization of its antitumor effects, and subsequently summarized the current research on its antitumor effects, especially in ESCC. A number of studies have reported that metformin prevents the development of ESCC and exerts its antitumor effects through various pathways. In addition, metformin has been shown to inhibit tumor growth, induce apoptosis, inhibit cancer cell invasion, migration and angiogenesis into the tumor, and decrease tumor malignancy, such as metastasis. Furthermore, it may modulate host tumor immunity in a tumor-suppressive manner and is expected to improve prognosis following treatment for ESCC. Notably, metformin may be beneficial in combination with chemotherapy, such as cisplatin, and radiation. By contrast, it has been shown to potentially induce resistance to 5-fluorouracil. Finally, the effects of metformin in combination with other therapies are discussed in the present study, and perspectives on the potential benefits of metformin for future ESCC treatment are presented. In conclusion, the present review may be useful in improving the understanding of the wide range of antitumor effects of metformin. Although some concerning points remain, using metformin in ESCC treatment could be promising. Notably, more knowledge needs to be accumulated regarding the effects of metformin on ESCC.

The Impact of Racial Disparities and the Social Determinants of Health on Esophageal and Gastric Cancer Outcomes

Reducing long-standing inequities in gastric and esophageal cancers is a priority of patients, providers, and policy makers. Many social determinants of health influence risk factors for disease development, incidence, treatment, and outcomes of gastric and esophageal cancers.

Global and regional quality of care index (QCI) by gender and age in oesophageal cancer: A systematic analysis of the Global Burden of Disease Study 1990-2019

BACKGROUND

The aim of this study was to examine the quality of care by age and gender in oesophageal cancer using Global Burden of Disease (GBD) database.

METHODS

Patients aged 20 and over with oesophageal cancer were included in this longitudinal study using GBD 1990-2019 data. We used the Socio-Demographic Index (SDI) to classify the regions. We used Principal Component Analysis (PCA) method to calculate the Quality of Care Index (QCI). The QCI was rescaled into a 0-100 single index, demonstrating that the higher the score, the better the QC.

RESULTS

The age-standardized QCI for oesophageal cancer dramatically increased from 23.5 in 1990 to 41.1 in 2019 for both sexes, globally. The high SDI regions showed higher QCI than the rest of the regions (45.1 in 1990 and 65.7 in 2019) whereas the low SDI regions had the lowest QCI, which showed a 4.5% decrease through the years (from 13.3 in 1990 to 12.7 in 2019). Globally, in 2019, the QCI showed the highest scores for patients aged 80-84, reported 48.2, and the lowest score for patients aged 25-29 reported 31.5, for both sexes. Globally, in 2019, age-standardized Gender Disparity Ratio (GDR) was 1.2, showing higher QCI in females than males.

CONCLUSION

There were fundamental differences in the QCI both globally and regionally between different age groups as well as between males and females. To achieve the goal of providing high-quality services equally to people in need in all over the world, health systems need to invest in effective diagnostic services, treatments, facilities, and equipment and to plan for screening and surveillance of high-risk individuals.

Neoadjuvant Radiotherapy Facility Type Affects Anastomotic Complications After Esophagectomy

BACKGROUND

Esophagectomy is a complex oncologic surgery that results in lower perioperative morbidity and mortality when performed in high-volume hospitals by experienced surgeons; however, limited data exists evaluating the importance of neoadjuvant radiotherapy delivery at high- versus low-volume centers. We sought to compare postoperative toxicity among patients treated with preoperative radiotherapy delivered at an academic medical center (AMC) versus community medical centers (CMC).

METHODS

Consecutive patients undergoing esophagectomy for locally advanced esophageal or gastroesophageal junction (GEJ) cancer at an academic medical center between 2008 and 2018 were reviewed. Associations between patient factors and treatment-related toxicities were calculated in univariate (UVA) and multivariable analyses (MVA).

RESULTS

One hundred forty-seven consecutive patients were identified: 89 CMC and 58 AMC. Median follow-up was 30 months (0.33-124 months). Most patients were male (86%) with adenocarcinoma (90%) located in the distal esophagus or GEJ (95%). Median radiation dose was 50.4 Gy between groups. Radiotherapy at CMCs resulted in higher rates of re-operation after esophagectomy (18% vs 7%, p = 0.055) and increased rates of anastomotic leak (38% vs 17%, p < 0.01). On MVA, radiation at a CMC remained predictive of anastomotic leak (OR 6.13, p < 0.01).

CONCLUSION

Esophageal cancer patients receiving preoperative radiotherapy had higher rates of anastomotic leaks when radiotherapy was completed at a community medical center versus academic medical center. Explanations for these differences are uncertain but further exploratory analyses regarding dosimetry and radiation field size are warranted.

Rural-Urban Disparities in Receipt of Surgery for Potentially Resectable Non-Small Cell Lung Cancer

INTRODUCTION

Access to cancer care, especially surgery, is limited in rural areas. However, the specific reasons rural patient populations do not receive surgery for non-small cell lung cancer (NSCLC) is unknown. We investigated geographic disparities in reasons for failure to receive guideline-indicated surgical treatment for patients with potentially resectable NSCLC.

METHODS

The National Cancer Database was used to identify patients with clinical stage I-IIIA (N0-N1) NSCLC between 2004 and 2018. Patients from rural areas were compared to urban areas, and the reason for nonreceipt of surgery was evaluated. Adjusted odds of (1) primary nonsurgical management, (2) surgery being deemed contraindicated due to risk, (3) surgery being recommended but not performed, and (4) overall failure to receive surgery were determined.

RESULTS

The study included 324,785 patients with NSCLC with 42,361 (13.0%) from rural areas. Overall, 62.4% of patients from urban areas and 58.8% of patients from rural areas underwent surgery (P < 0.001). Patients from rural areas had increased odds of (1) being recommended primary nonsurgical management (adjusted odds ratio [aOR]: 1.14, 95% confidence interval [CI]: 1.05-1.23), (2) surgery being deemed contraindicated due to risk (aOR: 1.19, 95% CI: 1.07-1.33), (3) surgery being recommended but not performed (aOR: 1.13, 95% CI: 1.01-1.26), and (4) overall failure to receive surgery (aOR: 1.21, 95% CI: 1.13-1.29; all P < 0.001).

CONCLUSIONS

There are geographic disparities in the management of NSCLC. Rural patient populations are more likely to fail to undergo surgery for potentially resectable disease for every reason examined.

Geographical Disparities in Esophageal Cancer Incidence and Mortality in the United States

BACKGROUND

Our previous research on neuroendocrine and gastric cancers has shown that patients living in rural areas have worse outcomes than urban patients. This study aimed to investigate the geographic and sociodemographic disparities in esophageal cancer patients.

METHODS

We conducted a retrospective study on esophageal cancer patients between 1975 and 2016 using the Surveillance, Epidemiology, and End Results database. Both univariate and multivariable analyses were performed to evaluate overall survival (OS) and disease-specific survival (DSS) between patients residing in rural (RA) and urban (MA) areas. Further, we used the National Cancer Database to understand differences in various quality of care metrics based on residence.

RESULTS

N = 49,421 (RA [12%]; MA [88%]). The incidence and mortality rates were consistently higher during the study period in RA. Patients living in RA were more commonly males (p < 0.001), Caucasian (p < 0.001), and had adenocarcinoma (p < 0.001). Multivariable analysis showed that RA had worse OS (HR = 1.08; p < 0.01) and DSS (HR = 1.07; p < 0.01). Quality of care was similar, except RA patients were more likely to be treated at a community hospital (p < 0.001).

CONCLUSIONS

Our study identified geographic disparities in esophageal cancer incidence and outcomes despite the similar quality of care. Future research is needed to understand and attenuate such disparities.

Disparities in thoracic surgical oncology

Disparities in access and outcomes of thoracic surgical oncology are long standing. This article examines the patient, population, and systems-level factors that contribute to these disparities and inequities. The need for research and policy to identify and solve these problems is apparent. As leaders in the field of thoracic oncology, surgeons will be instrumental in narrowing these gaps and moving the discipline forward.

Reduction in myocardial function and oxygen consumption after chemoradiotherapy in patients with esophageal cancer

BACKGROUND

Chemoradiotherapy (CRT) may induce myocardial dysfunction, congestive heart failure, and impaired physical performance in patients with esophageal cancer (EC). We aimed to investigate left ventricular (LV) function at rest and during stress, using echocardiography (echo) and a cardiopulmonary exercise (CPX) test both before and immediately after completing CRT.

MATERIAL AND METHODS

Consecutive EC patients referred for curative treatment were enrolled. Patients attended either definitive CRT or neoadjuvant CRT with subsequent surgery. The evaluation included cardiac biomarkers, electrocardiogram, echo, and CPX test. The primary endpoint was changes in left ventricular (LV) global longitudinal strain (GLS) at rest. Secondary endpoints were LV ejection fraction (LVEF), LV diastolic function, LVEF and GLS at peak exercise, and maximal oxygen consumption (VO_2max). The trial was registered with ClinicalTrials.gov (NCT03619317).

RESULTS

Among 47 patients enrolled (94% male; median age 67 years, range 50-86 years), cardiac examinations were performed a median of three days [Interquartile range (IQR (1-5))] before CRT and one day [IQR (0-6)] after CRT. At rest, GLS and LVEF decreased, 17.6 vs. 16.4% and 56.4 vs. 55.1%, respectively (p = 0.004; p = 0.030). Furthermore, an absolute decrease of at least 5% in LVEF and 2.5% in GLS was noted in 21% of the patients. Signs of LV diastolic dysfunction increased from 13 to 21% (p = ns). VO_2max significantly decreased; 21.2 ml/kg/min vs. 18.8 ml/kg/min (p < 0.001).

CONCLUSION

LV function and physical performance decreased in EC patients after CRT, and the LV systolic reserve capacity declined. This study highlighted that EC treatment was associated with early cardiac side effects, which may have clinical and prognostic implications.