Surgical Resection for Locoregional Esophageal Cancer Is Underutilized in the United States

BACKGROUND: Although esophagectomy provides the highest probability of cure in patients with esophageal cancer, many candidates are never referred for surgery. We hypothesized that esophagectomy for esophageal cancer is underused, and we assessed the prevalence of resection in national, state, and local cancer data registries. STUDY DESIGN: Clinical stage, surgical and nonsurgical treatments, age, and race of patients with cancer of the esophagus were identified from the Surveillance, Epidemiology and End Results (SEER) registry (1988 to 2004), the Healthcare Association of NY State registry (HANYS 2007), and a single referral center (2000 to 2007). SEER identified a total of 25,306 patients with esophageal cancer (average age 65.0 years, male-to-female ratio 3: 1). HANYS identified 1,012 cases of esophageal cancer (average age 67 years, M: F ratio 3: 1); stage was not available from NY State registry data. A single referral center identified 385 patients (48 per year; average age 67 years, M: F 3: 1). For SEER data, logistic regression was used to examine determinants of esophageal resection; variables tested included age, race, and gender. RESULTS: Surgical exploration was performed in 29% of the total and only 44.2% of potentially resectable patients. Esophageal resection was performed in 44% of estimated cancer patients in NY State. By comparison, 64% of patients at a specialized referral center underwent surgical exploration, 96% of whom had resection. SEER resection rates for esophageal cancer did not change between 1988 and 2004. Males were more likely to receive operative treatment. Nonwhites were less likely to undergo surgery than whites (odds ratio 0.45, p < 0.001). CONCLUSIONS: Surgical therapy for locoregional esophageal cancer is likely underused. Racial variations in esophagectomy are significant. Referral to specialized centers may result in an increase in patients considered for surgical therapy. (J Am Coll Surg 2010; 211: 754-761. (C) 2010 by the American College of Surgeons)