Racial and ethnic disparities in esophageal cancer survival are greatest at curable stages: a population-based study

BACKGROUND: Racial and ethnic disparities in esophageal cancer outcomes are documented, but whether they differ by stage at diagnosis is unclear. Using population-based data from Florida, a diverse, Medicaid non-expansion state, we conducted a stage-stratified analysis of racial/ethnic differences in survival and treatment receipt. METHODS: We analyzed 21,814 esophageal cancer cases from the Florida Cancer Data System (2005-2021). Using cause-specific Cox models, we estimated adjusted hazard ratios (aHRs) for cancer-specific mortality overall and by stage, adjusting for demographics, tumor characteristics, treatment, smoking, and socioeconomic factors. Multivariable logistic regression assessed racial/ethnic differences in receipt of surgery, chemotherapy, and radiation. RESULTS: Patients were 81.0% non-Hispanic (NH) White, 8.0% NH Black, and 10.0% Hispanic. NH Black patients had higher overall mortality than NH White patients (aHR: 1.08; 95% CI 1.02-1.15). Stage-stratified models showed elevated mortality among NH Black patients at localized (aHR: 1.24; 95% CI 1.05-1.45) and regional stages (aHR: 1.19; 95% CI 1.07-1.35) compared with NH White patients, but lower mortality at distant stage (aHR: 0.88; 95% CI 0.80-0.98). NH Black patients had lower odds of surgery (aOR: 0.51; 95% CI 0.43-0.61) and chemotherapy (aOR: 0.79; 95% CI 0.70-0.90) compared with NH White patients; radiation receipt did not differ. CONCLUSION: Survival disparities were most pronounced at curable stages, indicating inequities in post-diagnosis management. Lower treatment receipt and persistent survival differences after clinical adjustment suggest that structural and systemic factors contribute. These findings highlight a critical target for cancer control and underscore the need for system-level reforms to ensure equitable, stage-appropriate care.