Evaluating the Impact of Race and Ethnicity on Health-Related Quality of Life Disparities in Patients with Esophageal Cancer: A SEER-MHOS National Database Study.

BACKGROUND: It is unclear whether health-related quality of life (HRQOL) disparities exist between racial/ethnic groups in older patients with esophageal cancer, pre- and post-diagnosis. METHODS: Using the SEER-MHOS (Surveillance, Epidemiology, and End Results and Medicare Health Outcomes Survey) national database, we included patients ages 65-years-old or greater with esophageal cancer diagnosed from 1996 to 2017. HRQOL data within 36 months before and after diagnosis were measured by the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36 and VR-12 instruments. Total combined score (TCS) was reflected by both PCS and MCS. RESULTS: We identified 1,312 patients, with evaluable data on 873 patients pre-diagnosis and 439 post-diagnosis. On pre-diagnosis cohort MVA, the MCS was better for White over Hispanic patients (54.1 vs. 48.6, P = 0.012). On post-diagnosis cohort MVA, PCS was better for Hispanic compared with White (39.8 vs. 34.5, P = 0.036) patients, MCS was better for Asian compared with White (48.9 vs. 40.9, P = 0.034) patients, and TCS better for Asian compared with White (92.6 vs. 76.7, P = 0.003) patients. CONCLUSIONS: In older patients with esophageal cancer, White patients had better mental HRQOL as compared with Hispanic patients pre-diagnosis. However, post-diagnosis, White patients had worse mental and physical HRQOL compared with Asian and Hispanic patients, respectively, suggesting a greater negative impact on self-reported HRQOL in White patients with esophageal cancer. IMPACT: To our knowledge, this study is the first to explore HRQOL differences in patients with esophageal cancer of various racial and ethnic groups and warrants further validation in future studies.

The Dynamic Changing Incidence of Gastric Cancer in Israel: Time for a National Surgical Management Committee?

BACKGROUND: There has been a general reduction over the last 20 years in the incidence within Israel of gastric cancer (GC). This has particularly been noted in the Jewish population with a slight increase in the incidence of cancer of the gastroesophageal junction among Jews of Sephardi origin. Given the diversity of individual ethnic subpopulations, the effects of GC incidence in second-generation immigrant Jews, particularly from high prevalence regions (e.g., the former Soviet Union, Iraq, and Iran), awaits determination. There are currently no national data on GC-specific mortality. The most recent available cross-correlated Israeli National Cancer Registry (INCR) and International Association for Cancer Research (IARC) incidence data for GC of the body and antrum in Israel are presented. Some of the challenges associated with GC monitoring in the changing Israeli population are discussed. We propose the establishment of a national GC management committee designed to collect demographic and oncological data in operable cases with the aim of recording and improving GC-specific outcomes. We believe that there is value in the development of a national surgical planning program, which oversees training and accreditation in a dynamic environment that favors the wider use of neoadjuvant therapies, minimally invasive surgery and routine extended (D2) lymphadenectomy. These changes should be supported by assessable enhanced recovery programs.

Disparities in esophageal cancer: less treatment, less surgical resection, and poorer survival in disadvantaged patients.

The incidence of esophageal cancer has increased steadily in the last decades in the United States. The aim of this paper was to characterize disparities in esophageal cancer treatment in different racial and socioeconomic population groups and compare long-term survival among different treatment modalities. A retrospective analysis of the National Cancer Database was performed including adult patients (≥18 years old) with a diagnosis of resectable (stages I-III) esophageal cancer between 2004 and 2015. Multivariable logistic regression models were used to determine the odds of being offered no treatment at all and surgical treatment across race, primary insurance, travel distance, income, and education levels. Multivariable Cox proportional hazards models were used to compare 5-year survival rates across different treatment modalities. A total of 60,621 esophageal cancer patients were included. Black patients, uninsured patients, and patients living in areas with lower levels of education were more likely to be offered no treatment. Similarly, black race, female patients, nonprivately insured patients, and those living in areas with lower median residential income and lower education levels were associated with lower rates of surgery. Patients receiving surgical treatment, compared to both no treatment and definitive chemoradiation, had significant better long-term survival in stage I, II, and III esophageal cancer. In conclusion, underserved patients with esophageal cancer appear to have limited access to surgical care, and are, in fact, more likely to not be offered any treatment at all. Considering the survival benefits associated with surgical resection, greater public health efforts to reduce disparities in esophageal cancer are needed.

Presentation, Treatment, and Outcomes of Vulnerable Populations With Esophageal Cancer Treated at a Safety-Net Hospital.

Social determinants of health have been associated with poor outcomes in esophageal cancer. Primary language and immigration status have not been examined in relation to esophageal cancer outcomes. This study aims to investigate the impact of these variables on stage of presentation, treatment, and outcomes of esophageal cancer patients at an urban safety-net hospital. Clinical data of patients with esophageal cancer at our institution between 2003 and 2018 were reviewed. Demographic, tumor, and treatment characteristics were obtained. Outcomes included median overall survival, stage-specific survival, and utilization of surgical and perioperative therapy. Statistical analysis was conducted using Chi-square test, Fisher's exact tests, Kaplan-Meier method, and logistic regression. There were 266 patients; 77% were male. Mean age was 63.9 years, 23.7% were immigrants, 33.5% were uninsured/Medicaid, and 16.2% were non-English speaking. Adenocarcinoma was diagnosed in 55.3% and squamous cell in 41.0%. More patients of non-Hispanic received esophagectomies when compared to those of Hispanic origin (64% vs 25%, P = 0.012). Immigrants were less likely to undergo esophagectomy compared to US-born patients (42% vs 76%, P = 0.001). Patients with adenocarcinoma were more likely than squamous cell carcinoma patients to undergo esophagectomy (odds ratio = 4.40, 95% confidence interval 1.61-12.01, P = 0.004). More commercially/privately insured patients (75%) received perioperative therapy compared to Medicaid/uninsured (54%) and Medicare (49%) patients (P = 0.030). There was no association between demographic factors and the utilization of perioperative chemoradiation for patients with operable disease. Approximately 23% of patients with operable disease were too frail or declined to undergo surgical intervention. In this small single-center study, race and primary language were not associated with median survival for patients treated for esophageal cancer. US-born patients experienced higher surgical utilization and privately insured patients were more likely to receive perioperative therapy. Many patients with operable cancer were too frail to undergo a curative surgery. Studies should expand on the relationships between social determinants of health and nonclinical services on delivery of care and survival of vulnerable populations with esophageal cancer.

[Cost-effectiveness and cost-benefit analysis of upper gastrointestinal cancer screening in Yangzhong City, Jiangsu Province, from 2009 to 2015].

Objective: To evaluate the effectiveness and benefit of the upper gastrointestinal cancer screening in Yangzhong city, Jiangsu province, from 2009 to 2015. Methods: From 2009 to 2015, 31 natural villages with high-incidence of upper gastrointestinal cancer were selected from Baqiao town, Youfang town and Xinglong sub-district in Yangzhong city. 13 776 residents aged 40 to 69 years old were recruited and screened for upper gastrointestinal cancer by using endoscopic examination and pathological diagnosis. Two economic evaluation methods, cost-effectiveness analysis and cost-benefit analysis, were performed to evaluate the current screening schemes. Results: The mean age of all respondents were (53.60±8.14) years old and the males accounted for 43.64% (6 012). A total of 502 cases of upper gastrointestinal tract lesions were detected, including 100 cases of cancer (62 cases of esophagus, gastric/cardiac early stage cancer, 38 cases of advanced stage cancer), 38 cases of severe esophageal hyperplasia/carcinoma in situ, and 15 cases of high-grade intraepithelial neoplasia in stomach/cardia, the detection rate was 0.73%, 0.28% and 0.11%, respectively; the early diagnosis rate was 75.16% (115/153). The cost of a precancerous lesion, a case diagnosed at the early stage and a positive case identified through the upper gastrointestinal cancer screening in Yangzhong City was 10 037.17, 30 460.64 and 22 895.25 RMB, respectively. The early detection cost index from 2009 to 2015 was 0.52, 0.56, 0.48, 0.48, 0.21, 0.30, and 0.26, respectively. The effectiveness-cost ratio from 2009 to 2015 was 3.41, 2.77, 2.66, 2.58, 4.99, 3.12, and 3.48, respectively. Conclusions: The project of early diagnosis and treatment of upper gastrointestinal tract cancer in Yangzhong city has achieved good results and benefits.

Does serum albumin explain observed racial disparities in mortality for cancer patients undergoing esophagectomy?

BACKGROUND: African Americans with esophageal cancer have a higher mortality rate than Caucasians. We hypothesized that nutritional status, as reflected by preoperative albumin, might explain these disparities. METHODS: The National Surgical Quality Improvement Program database was queried for patients undergoing esophagectomy for esophageal cancer between 2005 and 2015. Preoperative albumin was divided into five categories (<3.0, 3.0-3.4, 3.5-3.9, 4.0-4.4, and >4.4). Univariate and multivariable regression statistics were performed to determine an association between preoperative albumin levels on mortality. RESULTS: 3228 patients were studied. While preoperative albumin was associated with lower body mass index, more severe preoperative weight loss, and more respiratory comorbidities (p-values <0.05), albumin levels were not associated with race. On multivariable models including race and other covariates, we found no association of serum albumin and mortality. CONCLUSIONS: We found that race was an independent predictor of mortality for patients undergoing esophagectomy. However, preoperative albumin did not explain these disparities.

Racial and Ethnic Disparities in the Incidence of Esophageal Cancer in the United States, 1992-2013.

Racial and ethnic disparities in the incidence of esophageal cancer have not been thoroughly characterized with quantitative health-disparity measures. Using data from 1992-2013 from 13 US cancer registries in the Surveillance, Epidemiology, and End Results database, we assessed such disparities according to histological type, based on a variety of disparity metrics. The age-standardized incidence rate of squamous cell carcinoma (SCC) was highest among black persons, while adenocarcinoma mainly affected white men. The rate of SCC decreased over time in all racial/ethnic groups, and this was most pronounced in black persons (by 5.7% per year among men and 5.0% among women). The adenocarcinoma rate rose among non-Hispanic whites and among black men. Racial/ethnic disparities in the incidence of total esophageal cancer decreased over time, which was due mainly to reduced disparities in SCC. The 2 absolute disparity measures-range difference and between-group variance-for adenocarcinoma rose by 3.2% and 6.8% per year, respectively, in men and by 1.8% and 5.3% per year, respectively, in women. This study demonstrates decreased racial/ethnic disparities in the incidence of esophageal SCC over time in the United States, while disparities increased in adenocarcinoma incidence as measured on the absolute scale.

Racial Disparity in the Sex Distribution, the Prevalence, and the Incidence of Dysplasia in Barrett's Esophagus.

GOALS: Our aim was to study the prevalence of dysplasia and progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) in African Americans (AA) with Barrett's esophagus (BE) and compare it with that of non-Hispanic white (NHW) controls. BACKGROUND: BE, a precursor of EAC, is a disease of predominantly white men and is uncommon in AA. The prevalence of dysplasia and progression to HGD and EAC in AA patients with BE is not clearly known. STUDY: All AA or NHW patients with confirmed BE, that is specialized intestinal metaplasia, seen between 2002 and 2013 at our institution were included. Variables such as age, gender, medication use, the body mass index, the date of endoscopy, the hiatal hernia size, the BE length, and histologic findings were noted. Progression to HGD/EAC was evaluated. RESULTS: Fifty-two AA and 2394 NHW patients with BE were identified. There was a higher percentage of women in the AA cohort (46.2%) than in the NHW cohort (24.9%, P<0.001). Nondysplastic BE was more prevalent in AA than in NHW (80.8% vs. 68.4%, P=0.058). In the surveillance cohort of 20 AA and 991 NHW, no racial differences in progression to HGD/EAC were observed during a median follow-up of 43 months. CONCLUSIONS: This study includes the largest number of AA with histologically confirmed BE reported so far. About 46.2% of the AA cohort with BE in our study consisted of women. There was a trend toward a higher prevalence of nondysplastic BE in AA compared with NHW.

The Race-Specific Incidence of Esophageal Squamous Cell Carcinoma in Individuals With Exposure to Tobacco and Alcohol.

OBJECTIVES: The relative impact of esophageal squamous cell carcinoma (ESCC) in minority populations is incompletely understood. We aimed to estimate the race-specific incidences of ESCC and place these in the context of the incidence of esophageal adenocarcinoma (EAC) in white men with gastroesophageal reflux disease (GERD). METHODS: The race- and sex-specific exposures to tobacco and alcohol in the United States were obtained from the National Health Interview Survey. The standardized incidence ratios of exposure to tobacco smoke and/or alcohol for ESCC were estimated from meta-analyses. Existing incidences of ESCC in the United States were obtained from the Surveillance, Epidemiology, and End Results (SEER) program. We then used this data to inform a Markov computer model estimating the incidence of ESCC. RESULTS: The incidence of ESCC reported in SEER was the greatest among African-Americans compared with white non-Hispanics, Hispanics, or Asians. In our model, the estimated incidence of ESCC in African-American men exposed to tobacco and alcohol approached the risk of EAC in white non-Hispanic men with weekly GERD. For instance, at age 60 years, the incidence of ESCC in African-American men who have used both tobacco and alcohol was 30/100,000 compared with an incidence of EAC in white men with GERD of 40/100,000. In comparison, the risk of EAC in white non-Hispanic women with weekly GERD at this age was 6.2/100,000. CONCLUSIONS: The incidence of ESCC in African-American men who use alcohol and tobacco is the highest and comparable to other screened diseases. Development of screening and prevention programs for ESCC in high-risk populations should be considered.

Racial disparities in esophageal cancer survival after surgery.

OBJECTIVES: Esophageal cancer (EC) black patients have higher mortality rates than Whites. The lower rate of surgery in Blacks may explain the survival difference. We explored the Surveillance Epidemiology and End Results database to determine the impact of surgery on mortality in Blacks and Whites EC. METHODS: All cases of pathologically proven local and locoregional adenocarcinoma and squamous cell carcinoma of the esophagus from 1973 to 2011 were identified (13,678 White, 2,894 Black patients). Cervical esophageal cancer was excluded. Age, sex, diagnosis year, stage, cancer-directed surgery, radiation, and vital status were analyzed according to self-reported race. RESULTS: Blacks had higher 1-year mortality, adjusted for age, sex, stage, year of diagnosis, histology, and therapy [adjusted hazard ratio (HRadj ): 1.24 (95% CI 1.16-1.32)]. Undergoing surgery was an independent predictor of improved survival overall (HRadj 0.30, 95% CI 0.27-0.33). Black patients treated surgically experienced significantly lower survival than Whites, but the difference was not observed in those who did not undergo surgery. CONCLUSIONS: Although surgery appears to reduce mortality overall, early survival is worse for Blacks. Investigation into racial disparities in health care access and delivery, and to skilled esophageal surgeons is warranted to improve survival for all patients, particularly Blacks. J. Surg. Oncol. 2016;113:659-664. © 2016 Wiley Periodicals, Inc.

Ethnic inequalities in time to diagnosis of cancer: a systematic review.

BACKGROUND: Minimising diagnostic delays in cancer may help improve survival. Ethnic minorities have worse outcomes in some cancer types when compared to the majority; this may relate in part to differences during the diagnostic phase. Only a few British studies have specifically explored this relationship, and no synthesis of these exists. The present study aimed to systematically review evidence on ethnic inequalities in cancer diagnosis, focussing on patient and primary care intervals of diagnosis. METHODS: Six electronic databases were searched. Included studies were those conducted in the UK or elsewhere (where access to healthcare is comparable to the NHS) and those that described a time element during diagnosis. Study quality was evaluated using the Critical Appraisal Skills Programme (CASP) checklist for cohort studies and synthesis method was narrative. RESULTS: Seven of 8,520 studies retrieved by our search met the review criteria; six conducted in the UK, and one in New Zealand. Five (including one covering several sites) focused on breast cancer, one on prostate, and one on oesophagogastric cancer. The studies employed different methods of ascertainment and definition of ethnic groups and defined diagnostic delay in a non-standardised way; therefore, narrative synthesis was performed. In breast cancer, three studies reported longer diagnostic intervals among ethnic minorities and two found no evidence of differences by ethnicity. There was some evidence of longer diagnostic and referral intervals among ethnic minorities in oesophagogastric and colorectal cancers, but no evidence of this in prostate, non-Hodgkin's lymphoma, lung, and ovarian cancers. None of the studies identified shorter patient or primary care intervals in ethnic minorities. CONCLUSIONS: Existing studies provide insufficient evidence to confirm or refute ethnic inequalities in diagnostic intervals of cancer. Further studies are necessary to examine common cancer types including those frequently found in ethnic minorities (in addition to those covered here) and using current definitions of intervals in cancer diagnosis.

Selected cancers with increasing mortality rates by educational attainment in 26 states in the United States, 1993-2007.

BACKGROUND: Mortality rates continue to increase for liver, esophagus, and pancreatic cancers in non-Hispanic whites and for liver cancer in non-Hispanic blacks. However, the extent to which trends vary by socioeconomic status (SES) is unknown. METHODS: We calculated age-standardized death rates for liver, esophagus, and pancreas cancers for non-Hispanic whites and non-Hispanic blacks aged 25-64 years by sex and level of education (≤12, 13-15, and ≥16 years, as a SES proxy) during 1993-2007 using mortality data from 26 states with consistent education information on death certificates. Temporal trends were evaluated using log-linear regression, and rate ratios (RRs) with 95 % confidence intervals (CIs) compared death rates in persons with ≤12 versus ≥16 years of education. RESULTS: Generally, death rates increased for cancers of the liver, esophagus, and pancreas in non-Hispanic whites and non-Hispanic blacks (liver cancer only) with ≤12 and 13-15 years of education, with steeper increases in the least educated group. In contrast, rates remained stable in persons with ≥16 years of education. During 1993-2007, the RR (rates in ≤12 versus ≥16 years of education) increased for all three cancers, particularly for liver cancer among men which increased from 1.76 (95 % CI, 1.38-2.25) to 3.23 (95 % CI, 2.78-3.75) in non-Hispanic whites and from 1.28 (95 % CI, 0.71-2.30) to 3.64 (95 % CI, 2.44-5.44) in non-Hispanic blacks. CONCLUSIONS: The recent increase in mortality rates for liver, esophagus, and pancreatic cancers in non-Hispanic whites and for liver cancer in non-Hispanic blacks reflects increases among those with lower education levels.

The spatial distribution of esophageal and gastric cancer in Caspian region of Iran: an ecological analysis of diet and socio-economic influences.

Recent studies have suggested a systematic geographic pattern of esophageal cancer (EC) and gastric cancer (GC) incidence in the Caspian region of Iran. The aims of this study were to investigate the association between these cancers and the region's dietary and socioeconomic risk factors and to map EC and GC after adjustment for the risk factors and the removal of random and geographic variations from area specific age standardised incidence ratios (SIRs). We obtained cancer data from the Babol cancer registry from 2001 to 2005, socioeconomic indices from the Statistical Centre of Iran, and dietary patterns from the control group in a case control study conducted in the study region. Regression models were fitted to identify significant covariates, and clusters of elevated rates were identified. We found evidence of systematic clustering for EC and GC in men and women and both sexes combined. EC and GC SIRs were lower in urban areas, and were also lower in areas of high income. EC SIRs were lower in areas with higher proportions of people having unrestricted food choice and higher in areas with higher proportions of people with restricted food choice. EC and GC were associated with aggregated risk factors, including income, urbanisation, and dietary patterns. These variables represent the influence of improved lifestyle which has coincided with a decrease in upper gastrointestinal cancer frequency over recent decades but which has not necessarily been uniform throughout the region.

Development, calibration, and validation of a U.S. white male population-based simulation model of esophageal adenocarcinoma.

BACKGROUND: The incidence of esophageal adenocarcinoma (EAC) has risen rapidly in the U.S. and western world. The aim of the study was to begin the investigation of this rapid rise by developing, calibrating, and validating a mathematical disease simulation model of EAC using available epidemiologic data. METHODS: The model represents the natural history of EAC, including the essential biologic health states from normal mucosa to detected cancer. Progression rates between health states were estimated via calibration, which identified distinct parameter sets producing model outputs that fit epidemiologic data; specifically, the prevalence of pre-cancerous lesions and EAC cancer incidence from the published literature and Surveillance, Epidemiology, and End Results (SEER) data. As an illustrative example of a clinical and policy application, the calibrated and validated model retrospectively analyzed the potential benefit of an aspirin chemoprevention program. RESULTS: Model outcomes approximated calibration targets; results of the model's fit and validation are presented. Approximately 7,000 cases of EAC could have been prevented over a 30-year period if all white males started aspirin chemoprevention at age 40 in 1965. CONCLUSIONS: The model serves as the foundation for future analyses to determine a cost-effective screening and management strategy to prevent EAC morbidity and mortality.

Esophageal cancer in Indigenous Australians in Far North Queensland.

BACKGROUND AND AIMS: There is very little information known about esophageal cancer in Indigenous persons. In this retrospective study, we investigated the epidemiological and clinical features of Indigenous Australians with esophageal cancer. METHODS: A retrospective study was carried out on Indigenous and non-Indigenous Australians diagnosed with esophageal cancer at Cairns Base Hospital during the period 1 January 2001 to 31 December 2006. Information was obtained from hospital medical records, Queensland Cancer Registry survival data and Queensland Health Pathology Services laboratory results. RESULTS: Thirteen Indigenous and 53 non-Indigenous patients were diagnosed with esophageal cancer. Squamous cell carcinoma accounted for a significantly higher proportion of esophageal cancers among Indigenous (11/13) than non-Indigenous patients (24/53) (P = 0.0135). Among patients with esophageal squamous cell cancer, Indigenous patients were more likely than non-Indigenous patients to present with metastatic disease (P = 0.0271) at a younger mean age (50.7 years vs 67.2 years; P = 0.0002). There was no significant difference between Indigenous and non-Indigenous patients concerning their mean survival time from date of biopsy (P = 0.7834) and whether patients had ever smoked (P = 0.0721) or consumed alcohol (P = 0.2849). CONCLUSION: There is a high incidence of squamous esophageal cancer in the Indigenous population in Far North Queensland. Indigenous persons tend to present at a younger age and with metastatic disease.

Epidemiology of esophageal cancer: Orient to Occident. Effects of chronology, geography and ethnicity.

Esophageal adenocarcinoma (EAC) has been rapidly increasing in Western countries during the past half century, especially in white men. Esophageal squamous cell carcinoma (ESCC) used to be the dominant type of esophageal malignancy both in Western and Asian countries. The rapid increase of EAC in Western countries has occurred in parallel with an increased prevalence of gastroesophageal reflux disease (GERD) and its major determinant, obesity. Such an increase in EAC has not yet been observed in Asia, despite a recent increase in prevalence of GERD. In this mini-review, we analyze possible factors influencing such east-west ('Orient to Occident') differences, particularly possible roles of ethnicity and environmental factors, such as Helicobacter pylori infection and nutritional factors, and how these might interact with socioeconomic differences. Development of Barrett's esophagus and esophageal adenocarcinoma appears to be strongly affected by ethnic factors, with populations resident at the west end of the Eurasian continent, such as Anglo-Celtics, being more prone to both conditions. On the other hand, ethnic groups from the eastern and southern ends of Eurasia, such as Chinese, Koreans and Japanese, and Africans might be more prone to developing esophageal squamous cell carcinoma. Future trends will also be discussed.

The effect of ethnicity on the presentation and management of oesophageal and gastric cancers: a UK perspective.

BACKGROUND: Studies show disparities in the management of oesophageal and gastric cancers between different ethnic groups. Asian patients with gastric adenocarcinoma present with less advanced disease and are more likely to undergo curative resection. For oesophageal cancer, the rate of surgery in Black patients is half that of Caucasians. However, these studies originate from the United States where demographics differ from that of the UK. METHODS: We undertook a 5-year retrospective audit of patients diagnosed with oesophageal and gastric cancers at City Hospital, Birmingham (UK), which serves three major ethnic groups: Caucasians, Blacks and Asians. RESULTS: Data were extracted from 244 patients' records that included 133 gastric and 111 oesophageal cancers. Caucasians were more likely to present within 3 months of symptom onset than Asians or Blacks. Asians were less likely to be referred for urgent endoscopy than Caucasians or Blacks (P<0.05). Significant differences in reported symptoms were found between ethnic groups with Caucasians more likely to report dysphagia and less likely to describe abdominal pain than other ethnic groups. There was a lower rate of curative operation for Asians but this did not reach significance. CONCLUSION: Ethnicity seems to influence health-seeking behaviour, with Caucasians more likely to present earlier for medical attention and Asian patients less likely to be referred for urgent endoscopy. Improvements in symptom education amongst patients and health professionals alike may accelerate referral and improve outcome. The favourable disease patterns reported in the United States 'Asians' and the lower surgery rates reported in the United States 'Blacks' are not shown in this UK population.

Esophageal cancer disparities in South Carolina: early detection, special programs, and descriptive epidemiology.

Because of its high fatality rate and our inability to detect esophageal disease early in its development, esophageal cancer represents a significant medical and public health challenge. The mortality statistics underline the importance of focusing on prevention of these conditions as a matter of state and national public health priority. Unfortunately, the measures needed for primary prevention of these conditions do not seem as clear-cut for populations at highest risk of this disease (i.e., AAs) as for the populations represented in most epidemiologic studies. Our incomplete knowledge about the etiology of esophageal cancer, especially squamous cell carcinomas in AAs and adenocarcinomas in EAs, preclude developing and disseminating effective preventive measures. Clearly, the prevention and control of esophageal cancers represent a different paradigm compared to other tobacco-related cancers of the upper aerodigestive tract. Data from a number of studies indicate that disparities exist in esophageal cancer incidence between racial groups and between geographical locations within South Carolina, and that these disparities are continuing to increase. The reasons for these disparities are only beginning to receive attention. They probably will be found to be complex and multifaceted. A combination of genetic factors, environmental influences (e.g., those related to diet), and the deleterious changes associated with smoking and alcohol consumption are the obvious parameters that should be the focus of initial epidemiologic data collection and assessment. Issues around dietary assessment, a major area of expertise among researchers in South Carolina, must be addressed in these studies. Much remains to be done for us to understand how research, health care, and educational efforts in the state of South Carolina might influence the detection, care, treatment, and, ultimately, reduction in esophageal cancer incidence and mortality rates. An important step in the process will be to coordinate data-collection efforts between clinicians, researchers, and concerned community members in South Carolina. This would allow comprehensive background profiles of patients to be collected for studies ranging from those focusing on the basic biology of the disease and its etiology to those aimed at understanding the role of health services and the effect of policy. In order to design and implement the full range of research needed to understand what we can do to prevent and control esophageal cancer in our state, it is our intention to engage all of the stakeholders within South Carolina; including community members, cancer survivors, cancer care providers, researchers, and individuals at high risk of esophageal cancer. With its large proportion of rural, socioeconomically deprived African Americans, what is learned about esophageal cancer in South Carolina will have national, and perhaps international, relevance.

A case-control study of endoscopy and mortality from adenocarcinoma of the esophagus or gastric cardia in persons with GERD.

BACKGROUND: This study assessed whether EGD reduces mortality from adenocarcinoma of the esophagus or gastric cardia for patients with gastroesophageal reflux. METHODS: A case-control study was performed. A total of 245 incident cases of death caused by adenocarcinoma of the esophagus or gastric cardia (1995-1999) in which reflux was present were identified using Veterans Health Administration databases. A total of 980 controls with reflux but no death from adenocarcinoma were frequency matched for age, gender, and race. The occurrences of EGD from 1990 onward were compared for cases and controls. Logistic regression analysis with adjustment for potential confounding factors was performed. RESULTS: All the subjects were men. Cases were significantly less likely to have had an EGD in the time period of interest as compared with controls (adjusted odds ratio 0.66: 95% CI [0.45, 0.96], p = 0.03). This negative association was as strong for any EGD performed within 1 to 8 years before diagnosis as for a more recent EGD. However, there were no controls that included esophagectomy and no controls with a nonfatal diagnosis of adenocarcinoma, raising the question of whether EGD and reduced mortality are causally linked. The risk of dying from adenocarcinoma was significantly lower for men with a diagnosis of GERD as an inpatient relative to men in whom the diagnosis was made as an outpatient (adjusted odds ratio 0.21: 95% CI [0.15, 0.31], p < 0.01). CONCLUSIONS: For patients with GERD, performing an EGD is associated with reduced mortality from adenocarcinoma of the esophagus or gastric cardia, but whether this is a causative association remains unclear.