Study Reveals Stark Disparities in Surgical Eligibility for Nonmetastatic Esophageal Cancer

A new analysis of national cancer data reveals that the decision to consider patients with nonmetastatic esophageal cancer as contraindicated for surgery varies significantly based on demographic factors and institutional practices, with over 1000-fold variation observed between institutions.

A total of 144 591 patients were included in the study, of whom 86% underwent surgical resection, 10% were deemed contraindicated, and 4% refused surgery. Multivariable analysis demonstrated that age, race, insurance status, comorbidities, and institutional volume significantly influenced contraindication status. Patients over age 70 who identified as non-Hispanic and Black, with Medicaid, or in the lowest income quartile, were significantly more likely to be deemed contraindicated.

Among cT1N0M0 patients with no comorbidities, patients aged over 80 years were over 7 times more likely to be considered contraindicated for surgery compared to younger patients (odds ratio [OR] 7.31, CI 4.66–11.48). Similarly, Black patients had 46% higher odds of being deemed ineligible compared to White patients (OR 1.46, CI 1.11–1.93), and those with Medicaid insurance were over 3 times as likely (OR 3.22, CI 2.19–4.73).

Institutional variation was striking. The study found “more than 1000-fold differences between individual programs regarding observed–expected ratio of contraindication status,” even when controlling for patient characteristics. Low-volume centers and comprehensive community programs had significantly higher rates of patients deemed contraindicated than high-volume academic centers.

“Underserved minorities, including age, race, and insurance type, are risk factors for being considered contraindicated,” the authors wrote. “These findings highlight the disparities that exist regarding surgical care of non-metastatic esophageal cancer in the United States.”

The study emphasizes that the absence of standardized criteria for determining surgical fitness creates space for subjective judgment, which may introduce bias and perpetuate disparities. The authors suggest that centralization of esophageal cancer care to high-volume centers may help reduce these inequities and standardize decision-making.

The authors conclude that improved access to surgical evaluation, particularly for underserved populations, and clearer guidelines for assessing surgical contraindications are critical for equitable cancer care.

Reference
Boutros CS, Drapalik LM, Alvarado CE, et al. Is there bias in the assessment of contraindications for resection? Disparities in the surgical management of early-stage esophageal cancer. Diseases. 2025; 13(2):37. doi:10.3390/diseases13020037