Previous research generally shows a higher cancer survival rate for white than black patients, after appropriate severity adjustments. Since no significant racial variation was found in utilization of surgery, chemotherapy, or radiation therapy for other types of cancer in the Veterans Administration Medical System (colorectal cancer) and the Department of Defense (prostate cancer), it is thought the racial disparities in cancer outcomes might be due to access to care. This study examines a national database of all VA hospitalizations and outpatient clinics to examine the use of surgery, radiation and chemotherapy, as well as mortality among white and black male veterans with esophageal cancer treated in VA hospitals. All white and black male patients newly diagnosed with distal esophageal cancer and gastric cardia between 1993 and 1995 were included. The sample size was 1,521 patients.

Several race differences in treatment were noted. Adjusting for age, comorbidity, marital status, type of VA eligibility status, and presence of metastases, blacks with adenocarcinoma were less likely to undergo surgical resection (OR=0.54) but were equally like to have radiation or chemotherapy. Among patients with SCC, black patients were less likely to undergo surgical resection (OR=0.45) yet more likely to have radiation and chemotherapy. There was no mortality difference for patients with adenocarcinoma, but blacks had a higher SCC mortality rate (RR=1.33). Black patients were also more likely to receive combined chemotherapy and radiation therapy for SCC, but not for adenocarcinoma.

Blacks with SCC were more likely to have had a CT scan, and CT scan was positively associated with the use of each procedure. Mortality was negatively associated with CT scan. There were no race differences among patients with adenocarcinoma in the use of CT scan.

Because race differences in use of surgical resection were found, related treatment patterns and consequences of these racial differences were evaluated. In the subgroup of surgical patients, blacks with SCC were less likely to received radiation and chemotherapy. Survival was significantly longer for black patients than for white patients.

Explanations offered by the authors for variation in esophageal cancer treatment and survival include "differences in attitudes toward invasive procedures, differences in disease severity, systematic racial bias, or differences in the utilization of hospitalization for cancer management." They also note "racial variation could be confounded by unmeasured biological factors in the clinical behavior of esophageal cancer." The observation of a racial difference in survival for SCC only (not adenocarcinoma) suggests "there may be underlying racial differences in either the clinical presentation or natural history of SCC."

The authors note that among patients with SCC, black patients who underwent surgery were more likely to have chemotherapy and radiation therapy. They conclude that black patients may have been discovered to have a higher unrecognized stage of disease at the time of surgery more often than whites and note that the lack of detail about tumor stage in the data makes it likely that adjustment for this variable was incomplete.