Do socioeconomic factors impair uptake of neoadjuvant therapy for patients with locoregional oesophageal cancer?

Objectives: The benefits of neoadjuvant therapy prior to surgery for patients with locally advanced oesophageal cancer have been well established by multiple trials. However, there may be socioeconomic barriers impacting equitable administration. We aim to identify whether disparities exist in the uptake of neoadjuvant therapy among patients with loco-regional oesophageal cancer.

Methods: We queried the National Cancer Database to identify patients with clinical stage II-III oesophageal cancer who underwent surgical resection (2006-2020). Logistic regression was performed to identify associations between sociodemographic factors and uptake of neoadjuvant therapy. In propensity score-matched groups, survival was evaluated using the Kaplan-Meier method.

Results: Among 19 748 clinical stage II-III patients, 85% (n = 16 781) received neoadjuvant therapy and 15% (n = 2967) underwent upfront surgery. Rates of neoadjuvant uptake increased over time. On multivariable analysis after adjusting by clinical stage, factors associated with lower rates of neoadjuvant therapy included older age (age ≥70, adjusted odds ratio 0.52; 95% confidence interval 0.47-0.57; P < 0.001), female sex (0.76; 0.69-0.85; P < 0.001), Black race (0.77; 0.63-0.94; P = 0.009), more comorbidities (0.76; 0.65-0.85; P < 0.001) and government rather than private insurance (0.84; 0.76-0.93; P < 0.001). In a propensity-matched cohort accounting for these variables, neoadjuvant treatment was associated with improved 5-year overall survival compared to upfront surgery (41.1% vs 35.4%, P < 0.001).

Conclusions: Several sociodemographic factors are associated with the delivery of neoadjuvant therapy in patients with oesophageal cancer, including age, sex, race, and insurance status. Interventions can be put into place to target vulnerable patients and ensure equitable delivery of care.