Abstract
PURPOSE Esophageal cancer (EC) can arise from the cricopharyngeal muscle to the lower esophageal sphincter. The disparity in anatomical location causes difficulty in clinical decision making and analysis of outcomes data. Previous studies show that Black patients are less likely to undergo surgical intervention and experience higher mortality in resectable disease. Studies relating EC location to outcomes are lacking. Data from the National Cancer Database (NCDB) were used to explore the effect that EC location and race has on survival. METHODS A retrospective cohort analysis of the NCDB included 167,189 patients diagnosed with a malignant neoplasm of the upper, middle, and lower third of the esophagus between the years 2004 and 2020. The impact of EC location on overall survival was analyzed by the Kaplan-Meier method. The impact of location against race on survival was compared using Cox Regression. RESULTS Of the 167,189 patients in the study 13,381 (8.0%) were Black, 2,959 (1.8%) were Asian, 1,444 (0.9%) were other, and 147,825 (88.4%) were White. 53.9%, 45.3%, and 28.4% of EC diagnosed in Black, Asian, and patients of other race, respectively, were of an upper or middle esophageal primary in contrast to 18.4% in white patients. There was a statistically significant increase in mean survival time in lower EC (48.5 months) vs. upper EC and middle EC (37 months and 37.7 months, respectively, p<.001). Multivariate analysis of cancer location and race showed there was a lower risk of death when comparing Asian patients and those of other race to White patients across all locations (hazard ratio (HR) .848 and .865, respectively, p<.001); however, there was a statistically significant increased risk of death in Black patients when compared to White patients (HR 1.238, p<.001). CONCLUSION Black, Asian, and other non-White patients are more likely to have upper or middle EC. Upper and middle EC portend a worse survival from diagnosis in comparison to lower EC. However, risk of death is only increased in Black patients with EC when compared to other races. These data suggest that decreased survival in upper and middle EC may be influenced not only by the primary site, but also by social determinants disproportionately affecting Black patients.