DISPARITIES IN GERD-ASSOCIATED ESOPHAGEAL ADENOCARCINOMA: THE ROLE OF DEMOGRAPHIC, CLINICAL AND SOCIOECONOMIC FACTORS IN DISEASE PROGRESSION

Introduction: Gastroesophageal reflux disease (GERD) is a key risk factor for esophageal adenocarcinoma (EAC) among other factors, such as Barrett’s esophagus (BE), advanced age, male sex, Caucasian race, and tobacco use. Socioeconomic status (SES) has an impact on prevention and early detection of several cancers. However, there is a paucity of data on the impact of SES on the progression from GERD to EAC. The aim of this study was to examine demographic, clinical and SES factors that predict progression from GERD to EAC in a large regional health network.

Methods: This was a cohort study of all patients diagnosed with GERD from 2015 to 2023 in a regional health network comprising 14 hospitals and >300 clinics. The outcome of interest was subsequent diagnosis of EAC. United States Census Bureau wealth and income, education and occupation data was used to calculate a SES summary score. Quintile SES scores were used to divide patients into lowest, low, mid, high and highest SES groups. Demographic, clinical, and SES factors were assessed for impact on progression from GERD to EAC using univariate followed by multivariable analysis.

Results: The study population consisted of 162,542 patients with GERD. Demographics were 40.1% male and 90.0% Caucasian with a mean (SD) age of 53.4(17) and BMI of 31.0(7). During the study period, 331(0.20%) patients progressed to EAC. Patients with EAC were more likely to be older [62.0(10) vs 53.3(17), p<0.0001], male (83.4% vs 40.0%, p<0.0001), Caucasian (94.6% vs 90.0%, p=0.031), have used tobacco (74.3% vs 56%, p<0.0001), and have BE (24.8% vs 4.6%, p<0.0001).
As SES increased from lowest to highest there was a significant decrease in the rate of EAC (0.27% vs 0.33% vs 0.26% vs 0.23% vs 0.16%, p=0.0008) and an increase in the median (IQR) number of endoscopic evaluations [4.3(1-14) vs 4.2(1-10) vs 4.5(1-12) vs 7.8(4-16) vs 13.4(3-23), p<0.0001]. Patients with EAC were more likely to be below median household income (37.8% vs 29.6%, p=0.0011), dropout of high school (6.3% vs 5.9% p=0.003), and less likely to graduate college (58.3% vs 61.1%, p<0.0001) and have private insurance (32.6% vs 50.3%, p<0.0001).
Multivariable analysis found that progression from GERD to EAC was associated with age ≥ 60 [OR:1.9 (95% CI:1.4-2.4), p<0.0001], male sex [OR:6.5 (95% CI:4.8-8.6), p<0.0001], Caucasian race [OR:1.5 (95% CI:1.0-2.5), p=0.076], tobacco use [OR:2.5 (95% CI:2.0-3.3), p<0.0001], BE [OR:4.9 (95% CI:3.8-6.3), p<0.0001], lack of private insurance [OR:1.4 (95% CI:1.1-1.9), p<0.0001], and low SES [OR:1.6 (95% CI:1.2-2.1), p<0.0001].

Conclusion: Patients with low SES underwent fewer endoscopic evaluations, lacked private insurance and were more likely to progress from GERD to cancer. In addition to known demographic and clinical risk factors, SES should be considered in EAC risk assessment.