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E. Carter Paulson, MD; Jin Ra, MD; Katrina Armstrong, MD, MSCE; Christopher Wirtalla, BA; Francis Spitz, MD; Rachel Rapaport Kelz, MD, MSCE

Arch Surg. 2008;143(12):1198-1203.

Hypothesis  Esophagectomy is underused as treatment for resectable stage I, II, and III esophageal cancers.

Design and Setting  Retrospective cohort study using the Surveillance, Epidemiology, and End Results–Medicare linked database.

Patients  We used the Surveillance, Epidemiology, and End Results database to identify persons 65 years or older who were not enrolled in a health maintenance organization and who were diagnosed as having stage I, II, or III esophageal cancer between January 1, 1997, and December 31, 2002 (N = 2386).

Main Outcome Measures  The rate of surgical intervention was compared across varying patient characteristics, including age, race, comorbidity score, sex, tumor stage, and socioeconomic region. Survival was compared between patients who received surgery and those who did not using Kaplan-Meier curves, the log-rank test, and Cox proportional hazards regression. Statistical analysis was performed using the ² test and multiple logistic regression.

Results  The overall rate of surgical intervention in this cohort was 34.1%. In all, 36.8% of white patients underwent surgical treatment of their disease, whereas only 19.2% of nonwhite patients did. Patients residing in areas with high poverty rates were 27% less likely to have surgery. Older age and higher comorbidity scores were also associated with lower rates of surgery. Patients who received surgical treatment for their disease experienced significantly longer survival than did patients who did not undergo surgical resection.

Conclusions  There seems to be significant underuse of esophagectomy as treatment for potentially resectable stage I, II, and III esophageal cancers across all patient groups. In nonwhite and low socioeconomic patient cohorts, the underuse is even more pronounced.

Author Affiliations: Departments of Surgery (Drs Paulson and Ra and Mr Wirtalla) and General Internal Medicine (Dr Armstrong) and Division of Endocrine and Oncologic Surgery, Department of Surgery (Drs Spitz and Rapaport Kelz), Hospital of the University of Pennsylvania, Philadelphia.

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