Black Americans Undertreated for Esophageal Cancer

Whites nearly twice as likely to receive life-prolonging surgery, study finds

THURSDAY, Jan. 20, 2005 (HealthDayNews) -- Even though surgery can extend the lives of many people with esophageal cancer, only 25 percent of black Americans have the procedure compared to 46 percent of white patients, a new study reports.

The prognosis for esophageal cancer is poor, with less than 10 percent of patients surviving beyond five years. But surgery to remove the cancer enables approximately 20 percent of patients to survive beyond that time.

"If black patients undergo surgery, their survival is similar to that of white patients undergoing surgery. Yet we found that there was a twofold difference in rate of surgery, and this difference may explain why African-Americans experience a lower rate of survival," said the study author Ewout W. Steyerberg, a Netherlands scientist.

Study co-author Dr. Craig C. Earle, of Boston's Dana-Farber Cancer Institute, added: "There seems to be a problem with access to care for black patients."

The study results appear in the Jan. 20 issue of the Journal of Clinical Oncology.

In the study of 2,946 white patients and 367 black patients with esophageal cancer, 25 percent of the whites were alive two years after diagnosis, compared to 18 percent of the blacks.

The authors suggested that black Americans could have less trust in doctors than white patients do, and that might make them more reluctant to undergo surgery.

However, they wrote, "our finding that survival differed little by race among those who underwent surgery supports the value of intervention to increase the use of surgery among black patients with esophageal cancer."

Stephanie Johnson, a Duke University psychologist who heads a program to reduce the health disparities that exist in the black community, said that historic mistrust of doctors means black Americans often hear a doctor's recommendation differently than a white patient does.

"There are cultural nuances that are included in the decisions that African-Americans make because of the mistrust they have of the medical community," she said. "Physicians often aren't aware of this -- they're just trying to do their jobs."

Steyerberg is a scientist at the Center for Clinical Decision Sciences at the Erasmus MC, University Medical Center in the Netherlands. For the study, he and his Dana-Farber colleagues reviewed Medicare records of esophageal cancer patients whose cancer had not spread. All the patients were at least 65 at the time of diagnosis, and the researchers controlled the study for age, sex, type of esophageal cancer, stage of the disease and other health problems.

Compared to the white patients, the black patients were slightly younger, had less money, and had more preexisting diseases, such as heart disease and diabetes. They also were more likely to have squamous cell cancer, which arises in the middle or upper part of the esophagus. The other common type of esophageal cancer, called adenocarcinoma, begins in the lower part of the esophagus, near the stomach, the researchers said.

Surgery is the most common form of treatment for esophageal cancer, although radiotherapy is also used.

The researchers found that black patients with esophageal cancer were less often assessed by a surgeon than were white patients, 70 percent vs. 78 percent. And of those seen by a surgeon, only 35 percent of the black patients underwent surgery, compared to 59 percent of the white patients.

Despite the fact that the rate of esophageal cancer is three times higher among black Americans than whites, black patients were generally undertreated for their cancer, compared to white patients.

Twenty percent of black patients received radiotherapy as their only treatment, compared to 13 percent of white patients. And 26 percent of black patients received no treatment at all, while 15 percent of white patients were untreated, according to the researchers.

In a related study, researchers at the Department of Veterans Affairs Medical Center in White River Junction, Vt., reported that adenocarcinoma cancer has increased nearly sixfold in the last 25 years.

The researchers, writing in the current Journal of the National Cancer Institute, found that an estimated 14,000 Americans in 2004 were diagnosed with esophageal cancer, divided fairly equally between squamous cell and adenocarcinoma cancers.

More information

To learn more about esophageal cancer and its treatment, visit the American Cancer Society.

SOURCES: Ewout W. Steyerberg, Ph.D., Center for Clinical Decision Sciences, Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands; Craig C. Earle, M.D., assistant professor, medicine, Harvard Medical School, Dana-Farber Cancer Institute, Boston; Stephanie Johnson, Ph.D., clinical associate, department of psychiatry, and research associate, Duke University Medical Center's Bryan Alzheimer's Disease Research Center, Durham, N.C.; Jan. 20, 2005, Journal of Clinical Oncology; Jan. 19, 2005, Journal of the National Cancer Institute
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