Where You Live and Where You Are Treated: Addressing Disparities in Esophageal Adenocarcinoma

BACKGROUND: Lower socioeconomic status conveys a known survival disadvantage for patients with esophageal adenocarcinoma (EAC). The potential role of the treating center volume in mitigating this disparity has not been described to date. METHODS: Non-metastatic EAC patients were identified (NCDB 2012-2021). High- and low-risk zip code groups were derived from income and education quartiles. Center volume was delineated as "low" or "high," with an annual threshold of ≥ 10 esophagectomies. Standard chi-square modeling, multivariable Cox hazard regression models, and Kaplan-Meier survival analyses were used where appropriate. RESULTS: Of 7462 EAC patients, 38.2% (n = 2849) resided in high-risk zip code areas, and 87.1% were treated at low-volume centers. Clinical (p = 0.230) and pathologic (p = 0.992) staging distribution did not differ across zip codes. High-volume centers saw a slightly increased proportion of advanced disease (p = 0.001). Patients at high-volume centers experienced better survival (5-year overall survival [5yOS], 44.97%) than their low-volume counterparts (5yOS, 40.62%) (p < 0.001). Patients residing in high-risk zip code areas demonstrated worse 5yOS than their low-risk counterparts (38.20% vs 43.74%; p < 0.001). Evaluation of low-volume centers showed that the high-risk zip code group had shorter survival than their low-risk counterparts (36.80% vs 43.21%; p < 0.001). Interestingly, in high-volume centers, survival across zip code groups was notably comparable (45.69% vs 46.20%; p = 0.80). CONCLUSIONS: Center expertise may offer an avenue for mitigating sociodemographic survival disparities in esophageal cancer. As discussions regarding centralized oncologic care continue, particular attention should be paid to the impact of high-volume center referral on the treatment of patients with social risk factors.