1. Black Patients Die Earlier after Surgery for Esophageal Cancer Andrea S. Wolf, MD, MPH, Emanuela Taioli MD, PhD, Marlene Camacho-Rivera, ScD, MPH, Andrew Kaufman, MD, Dong-Seok Lee, MD, Faiz Bhora, MD, Raja M. Flores, MD Department of Thoracic Surgery The Icahn School of Medicine at Mount Sinai The Mount Sinai Health System New York, NY

2. No financial disclosures

3. Introduction Esophageal cancer in black patients  Higher incidence and mortality  Higher rate of squamous cell CA  Lower use of surgery  When adjusted for surgery, no difference in survival

4. Objective To determine whether race affects short and long-term mortality in patients having surgery for esophageal cancer using SEER

5. Methods SEER 1973-2011 Inclusion: Blacks, Whites Adenocarcinoma, SCC Exclusion: Distant metastases Cervical esophageal CA

6. Methods Cox proportional hazards model Outcome: Overall survival Predictors: Race Age Sex Year of dx Stage Cancer-directed surgery Radiation

7. Baseline characteristics VariableCategories Whites (n = 13,678) Blacks (n = 2,894) p-value SexMale10,168 (74%)2,079 (72%)0.005 Female3,510 (26%)815 (28%) Mean age in yr (95% CI) 67.8 (67.6-68.0)61.6 (61.2-61.9)<0.0001 Overall Stage Localized6,609 (48%)1,508 (52%)<0.0001 Regional7,069 (52%)1,386 (48%) Histology SCC6,775 (50%)2,777 (96%)<0.0001 Adenocarcinoma6,903 (50%)117 (4%) Cancer-directed surgery No6,428 (47%)1,726 (60%)<0.0001 Yes7,250 (53%)1,168 (40%) Radiation No4,960 (36%)935 (32%)<0.0001 Yes8,476 (62%)1,870 (65%) Unknown242 (2%)89 (3%) Therapy None 1,619 (12%)411 (14%) <0.0001 Surgery only 3,341 (25%)524 (19%) Radiation only 4,678 (35%)1,258 (45%) Both surgery and radiation 3,798 (28%)612 (22%)

8. Incidence over time

9. Cox model 1-year mortality OverallSCCAC Variable Adjusted HR (95% CI) Race Black versus White1.24 (1.16-1.32)1.21 (1.13-1.30)1.06 (0.77-1.45) SexFemale versus Male 0.95 (0.90-1.01)0.94 (0.88-1.00)0.97 (0.86-1.09) AgePer increased year 1.02 (1.01-1.02)1.01(1.01-1.02)1.02 (1.02-1.02) Stage Regional versus Localized 1.60 (1.53-1.69)1.48 (1.39-1.58)1.78 (1.63-1.94) Histology SCC versus AC1.22 (1.15-1.30) -- TherapyNone 1.0 (REF) Surgery only0.30 (0.27-0.33)0.31 (0.28-0.35)0.27 (0.24-0.31) Radiation only0.56 (0.52-0.60)0.53 (0.48-0.58)0.63 (0.56-0.72) Both surgery and radiation 0.34 (0.31-0.37)0.36 (0.32-0.40)0.30 (0.26-0.35) Year of Diagnosis Per increased year 0.97 (0.97-0.97)0.97 (0.97-0.98)0.96 (0.96-0.97)

10. Cox model 1-year mortality OverallSCCAC Variable Adjusted HR (95% CI) RaceBlack versus White 1.24 (1.16-1.32)1.21 (1.13-1.30)1.06 (0.77-1.45)

11. Cox model 1-year mortality OverallSCCAC Variable Adjusted HR (95% CI) StageRegional versus Localized 1.60 (1.53-1.69)1.48 (1.39-1.58)1.78 (1.63-1.94)

12. Cox model 1-year mortality OverallSCCAC Variable Adjusted HR (95% CI) HistologySCC versus AC1.22 (1.15-1.30)--

13. Cox model 1-year mortality OverallSCCAC Variable Adjusted HR (95% CI) Therapy None1.0 (REF) Surgery only0.30 (0.27-0.33)0.31 (0.28-0.35)0.27 (0.24-0.31) Radiation only0.56 (0.52-0.60)0.53 (0.48-0.58)0.63 (0.56-0.72) Both surgery and radiation 0.34 (0.31-0.37)0.36 (0.32-0.40)0.30 (0.26-0.35)

14. Localized esophageal cancer

15. Treated with surgery

16. Without treatment

17. Localized esophageal cancer SurgeryNo treatment

18. Treated with surgery

19. Conclusions Black race is independently associated with higher mortality in esophageal cancer Black patients treated with surgery have poorer survival than Whites Racial difference in mortality most pronounced at first year

20. Future directions Differences in how black and white patients are being selected for surgery? Racial disparities in access to dedicated thoracic surgeons doing safe esophagectomies at high volume centers? Disparities in treatment at cancer centers with coordinated multi-disciplinary care?

21. Thank You

25. Baseline Characteristics VariableCategories Whites (n = 13,678) Blacks (n = 2,894) p-value SexMale10,168 (74%)2,079 (72%)0.005 Female3,510 (26%)815 (28%) Mean age in yr (95% CI) 67.8 (67.6-68.0)61.6 (61.2-61.9)<0.0001 Overall Stage Localized6,609 (48%)1,508 (52%)<0.0001 Regional7,069 (52%)1,386 (48%) Histology SCC6,775 (50%)2,777 (96%)<0.0001 Adenocarcinoma6,903 (50%)117 (4%) Cancer-directed surgery No6,428 (47%)1,726 (60%)<0.0001 Yes7,250 (53%)1,168 (40%) Radiation No4,960 (36%)935 (32%)<0.0001 Yes8,476 (62%)1,870 (65%) Unknown242 (2%)89 (3%) Therapy None 1,619 (12%)411 (14%) <0.0001 Surgery only 3,341 (25%)524 (19%) Radiation only 4,678 (35%)1,258 (45%) Both surgery and radiation 3,798 (28%)612 (22%)

26. Cox model 1-year mortality OverallSCCAC Variable Adjusted HR (95% CI)* RaceBlack versus White 1.24 (1.16-1.32)1.21 (1.13-1.30)1.06 (0.77-1.45) SexFemale versus Male 0.95 (0.90-1.01)0.94 (0.88-1.00)0.97 (0.86-1.09) AgePer increased year 1.02 (1.01-1.02)1.01(1.01-1.02)1.02 (1.02-1.02) StageRegional versus Localized 1.60 (1.53-1.69)1.48 (1.39-1.58)1.78 (1.63-1.94) HistologySCC versus AC 1.22 (1.15-1.30) -- TherapyNone 1.0 (REF) Surgery only 0.30 (0.27-0.33)0.31 (0.28-0.35)0.27 (0.24-0.31) Radiation only 0.56 (0.52-0.60)0.53 (0.48-0.58)0.63 (0.56-0.72) Both surgery and radiation 0.34 (0.31-0.37)0.36 (0.32-0.40)0.30 (0.26-0.35) Year of Diagnosis Per increased year 0.97 (0.97-0.97)0.97 (0.97-0.98)0.96 (0.96-0.97)

27. Cox model 3-year mortality OverallSCCAC Variable Adjusted HR (95% CI)* RaceBlack versus White 1.24 (1.17-1.30)1.22 (1.15-1.29)1.09 (0.86-1.39) SexFemale versus Male 0.94 (0.89-0.98)0.91 (0.87-0.96)0.98 (0.90-1.07) AgePer increased year 1.01 (1.01-1.02) 1.02 (1.01-1.02) StageRegional versus Localized 1.67 (1.60-1.73)1.47 (1.40-1.55)1.90 (1.78-2.03) HistologySCC versus AC 1.15 (1.10-1.21) -- TherapyNone 1.0 (REF) Surgery only 0.33 (0.31-0.36)0.37 (0.33-0.41)0.29 (0.26-0.33) Radiation only 0.64 (0.60-0.68)0.59 (0.54-0.64)0.74 (0.66-0.82) Both surgery and radiation 0.42 (0.39-0.45)0.42(0.38-0.46)0.41 (0.37-0.46) Year of Diagnosis Per increased year 0.97 (0.97-0.97)0.97 (0.97-0.98)0.96 (0.96-0.96)

28. Cox model overall mortality OverallSCCAC Variable Adjusted HR (95% CI)* RaceBlack versus White 1.25 (1.19-1.31)1.23 (1.17-1.29)1.04 (0.83-1.30) SexFemale versus Male 0.91 (0.88-0.95)0.89 (0.85-0.94)0.98 (0.90-1.06) AgePer increased year 1.02 (1.01-1.02)1.01(1.01-1.02)1.02 (1.02-1.03) StageRegional versus Localized 1.60 (1.55-1.66)1.44 (1.38-1.51)1.78 (1.68-1.89) HistologySCC versus AC 1.13 (1.09-1.18) -- TherapyNone 1.0 (REF) Surgery only 0.37 (0.34-0.39)0.40 (0.36-0.44)0.33 (0.30-0.37) Radiation only 0.69 (0.65-0.74)0.64 (0.59-0.70)0.79 (0.71-0.87) Both surgery and radiation 0.47 (0.44-0.50)0.47(0.43-0.51)0.47 (0.42-0.52) Year of Diagnosis Per increased year 0.97 (0.97-0.97)0.98 (0.97-0.98)0.96 (0.96-0.96)