Racial Disparities Flood the Esophageal Cancer Space


In an interview with Targeted Oncology, Allan Pickens, MD, discussed research on racial disparities in surgery for esophageal cancer.

Allan Pickens, MD

Allan Pickens, MD

While advancements in multimodal treatments have been made in the esophageal cancer space, improving patient outcomes, they have not benefited all races equally.

For patients with esophageal cancer, major disparities exist as minorities undergo fewer surgical resections of esophageal cancer and end up having worse outcomes.

Research published in the Thoracic Surgery Clinics by Allan Pickens, MD, delved into learning more about the racial disparities which exist on the surgical side of esophageal cancer and how they can affect the treatment of patients with esophageal cancer who are underrepresented or minorities.

“What we've found in looking at the data is that it tends to have a more devastating effect in the minority populations. There is poor survival of esophageal cancer in minorities. We are looking at the multifactorial causes of that, 1 being access to early diagnosis and treatment.” said Pickens, thoracic surgeon at Emory University, program director for cardiothoracic surgery residencies and the director of Medical Oncology, in an interview with Targeted OncologyTM.

Some ways to raise awareness about the racial disparities seen in the esophageal cancer space include making education more accessible, discussing the various opportunities for early diagnosis, and providing patients with upfront information regarding the symptoms of esophageal cancer.

In the interview, Pickens, further discussed his research on racial disparities in esophageal cancer.

Targeted Oncology: What does the current treatment landscape for patients with esophageal cancer consist of?

Pickens: Esophageal cancer has devastating effects on patients in terms of it being a very lethal tumor. The treatments that we have available for esophageal cancer have not made significant leaps and bounds over the past 10-20 years in the sense that we have not had a lot of new drugs on the market and not a lot of new procedures to combat it. The 1 advancement we have made is in early detection of esophageal cancer, including much more aggressive screening programs for Barrett's dysplasia, and other forms of premalignant lesions that lead to esophageal cancer.

In the earlier diagnosis of esophageal cancer, we have better opportunities to treat porousness. If we find something that's contained to the surface or mucosal layer of the esophagus, we can use some of the ablative techniques to take care of it. There's something called endoscopic mucosal resection, where we take away a portion of the lining of the esophagus with the tumor contained in it. Those don't interfere with the traditional surgical procedures that we have available. If those fail, we can then do a surgical resection to completely remove a early-stage esophageal cancer. The problem lies when we don't make the diagnosis early and these tumors have grown through the wall of the esophagus into our surrounding structures. This leads to a much worse outcome when it goes to lymph nodes and things that are outside of the esophagus.

Can you discuss your research on racial disparities in the esophageal cancer space?

The work that we've done in terms of racial disparity has been more from the surgical side of things, including how we can affect the surgical treatment of esophageal cancer in underrepresented minorities. What we've found in looking at the data is that it tends to have a more devastating effect in the minority populations. There is poor survival of esophageal cancer in minorities. We are looking at the multifactorial causes of that, 1 being access to early diagnosis and treatment. The fact that many minorities are often offered the nonsurgical options for treatment, they are more likely to proceed with definitive chemoradiation as opposed to surgical procedures. That mostly been related to access to surgeons or qualified surgeons to do their procedures at smaller hospitals and smaller, more underrepresented communities.

Perhaps there are not dedicated esophageal cancer surgeons that can take care of it. If they're required to travel hours away to a center of excellence that has those physicians, they may not have the resources to do that. So how do we help in those situations? How do we make virtual visits with physicians in other locations available so that [patients] only have to make 1 visit for the pre-op and perhaps the actual operation? Then, they can go back to their community and get their follow-up care with physicians that they are in contact with. Looking at that disparity and how it affects the survival of soft tissue cancers is truly important.

What was the design of the study and how did it help to get these results?

One of the more recent ones was a meta-analysis of all of the literature in the current marketplace. We looked at several studies that were done through the [National Cancer Institute] and the other organizations that fund extensive and basic science research to look at how it affected the incidence of esophageal cancer. We then looked at treatment in terms of how various centers decided who would get certain forms of treatment. We went through the actual protocols and recommendations that were placed nationally for care of esophageal cancer, and we looked at any papers that addressed surgical outcomes of esophageal cancers. From those, we pulled together a meta-analysis and came up with some statements about what is currently being done in the marketplace. Much of what I've done is focused on clinical research as opposed to basic science or benchtop research that are focusing on drugs that treat esophageal cancer.

What needs to be done to better outcomes for all races?

One is making education for the community more accessible. Letting people know about the opportunities for early diagnosis, making the symptoms of esophageal cancer more at the forefront of discussion, letting people know that the difficulty of swallowing and having food get stuck is not normal. That is something that can be an early sign of esophageal cancer. A random spitting up of bloody sputum can be a more advanced sign. What we commonly write off as indigestion may not necessarily be indigestion. It can be related to indigestion and reflux that have now led to an esophageal cancer, so public education is important.

From that, we need to move into screening and early diagnosis. How do we make it more accessible? How do we make it more of a standard for people to get their reflux evaluated with an endoscopy? That's not currently the norm. Unless you are found to have something wrong or have a symptom, most insurance carriers will not pay for a endoscopy. So how do we make that part of our screening process? That will involve having various organizations lobby for these improved survival results from people that are screened, people that are at a higher risk and have the predisposing factors of esophageal cancer.

From that, going into the cutting-edge drugs that are coming on the market. The treatments are rapidly evolving with all the immunotherapies that are being brought into the marketplace with the treatment of various cancers. How do we prove in a scientific way that those will be beneficial for esophageal cancer and then educate physicians on enrolling patients in these new protocols for treatment of esophageal cancer? For a long time, we only had a limited number of drugs that we used for many years, and they hadn't changed survival much. The survival for esophageal cancer remains 15%-20% at a 5-year period after diagnosis of all comers with esophageal cancer. So how do we improve that? One way of doing that is with better drugs to treat it, better radiation protocols, and on top of that, earlier opportunities for surgical intervention for patients that have their tumor contained in the esophagus and haven't had it spread to other places.

Then, doing good quality operations. We have several via national thoracic organizations that very closely follow the esophageal surgery outcomes of each individual surgeon. Esophageal surgery is a slightly more complex operation that not necessarily every surgeon has the technical ability to do or has the resources to take care of those patients after surgery. Having Centers of Excellence identified and having people know where to go to get that quality care for esophageal cancer is truly important. We also have minimally invasive thoracic procedures now to remove the esophageal cancer that comes from minimally invasive esophagectomy or robotic esophagectomy. All methods of taking out the esophagus that may make patients that were not necessarily a candidate for resection resectable because we can do it in a minimally invasive fashion and not necessarily the larger operation, given that most of these patients are older and more debilitated after being treated with chemo and radiation.

What unmet needs remain in this space and what can be done to help raise awareness what was discussed?

Unmet needs for esophageal cancer care relate to early diagnosis. We intervene with esophageal cancer in later phases, most often because patients have to progress to obstruction or difficulty or bleeding. By that time the horse is out of the barn, so to speak. We want to find those patients with early stages of esophageal cancer, stage I, where we can have a more increased opportunity for curative resection if we're going to perform an operation. Earlier screening, earlier diagnosis, and if they are not identified in that early phase, how do we get more patients enrolled in trials that give them the most cutting edge, novel therapy for treatment of their advanced esophageal cancer? Many patients don't know of those opportunities, and they get treated with the traditional methods that has not been as successful.

I think increasing awareness of the Centers of Excellence for esophageal cancer care is something that is not always discussed by everyone. Many centers across the country will do less than 8-10 esophagectomies a year. That doesn't always provide the proficiency in doing the operation or the staff that is accustomed to taking care of those patients. So acknowledging through our national organizations, such as the Society of Thoracic Surgeons, where these centers of excellence are located and having patients seek out quality surgical care would be another opportunity for improvement for us.

Pickens A. Racial Disparities in Esophageal Cancer. Thorac Surg Clin. 2022;32(1):57-65. doi:10.1016/j.thorsurg.2021.09.004
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