Upper Gastrointestinal Cancer Incidence-Based Mortality Is Highest in Racial and Ethnic Minority Groups Not Prioritized by Current Screening Paradigms

Introduction: Current strategies for upper gastrointestinal (UGI) cancer screening focus on cancer-specific risk, and particularly on esophageal adenocarcinoma (EAC). A cumulative cancer approach is best tailored to a single upper endoscopic screening exam. This study aims to assess cumulative incidence-based mortality (IBM) of all UGI cancers to compare cumulative and cancer-specific racial/ethnic and sex disparities. Methods: All analyses were performed using Surveillance, Epidemiology, and End Results Research data covering 17 cancer registries and approximately 26.5% of the United States population. Data for patients 20 years old or greater who were diagnosed with EAC, esophageal squamous cell carcinoma (ESCC), cardia gastric cancer (CGC), non-cardia gastric cancer (NCGC), or colorectal adenocarcinoma (CRC) from 2000 to 2019 were extracted. Colorectal cancer data is shown as a comparison since population-wide endoscopic screening is performed for this cancer. Age-adjusted incidence-based mortality (IBM) was calculated as a rate per 100,000 population and measures death among incident cases, providing more accuracy for deaths attributable to cancer compared to death certificate mortality. IBM was stratified by sex and race/ethnicity. Results: Cumulative IBM from upper GI cancers is highest among Blacks (10.61) and higher among all minority groups (8.62-10.61) compared to non-Hispanic whites (7.80, P< 0.01, Figure 1, panel A). For EAC and CGC, IBM is highest among non-Hispanic whites (2.90 and 1.83 respectively, Table 1). For ESCC, IBM is highest among Blacks (3.16, p < 0.01). For NCGC, IBM is highest among Asian/Pacific Islanders (4.02, P< 0.01). IBM from ESCC among Blacks as well as IBM from NCGC among all minority groups is higher than IBM from EAC among non-Hispanic whites (p < 0.02). IBM from UGI cancer in males (13.19) is not significantly different than IBM from CRC in women (13.28, p = 0.24, Figure 1, panel B). IBM from UGI cancers among Black, Hispanic, and American Indian/Alaska Native males (16.43, 13.76, and 15.23 respectively) is greater than IBM from CRC among white women (13.26, p < 0.01). Conclusion: This study highlights the extent and patterns of disparities in UGI cancer mortality. These cancers have a significantly higher mortality burden for nonwhite populations that are currently not targeted by any systematic population-level screening approach. Current screening approaches must be reevaluated to reduce these health disparities.Figure 1.: Comparative Analysis of Cancer-Specific and Cumulative Upper Gastrointestinal Cancer Incidence-Based Mortality. (A) Stratified by race/ethnicity, (B) Stratified by sex (cumulative only). Abbreviations: EAC = esophageal adenocarcinoma, ESCC = esophageal squamous cell carcinoma, CGC = cardia gastric cancer, NCGC = non-cardia gastric cancer, UGI = upper gastrointestinal tract cancer, CRC = colorectal adenocarcinoma. All rates per 100,000. Table 1. - Incidence-Based Mortality Stratified by Sex and Race/Ethnicity Incidence-Based Mortality (Rates per 100,000, 95% CI) EAC ESCC CGC NCGC UGI CRC Overall 2.26 (2.23-2.29) 1.21 (1.18-1.23) 1.60 (1.57-1.62) 2.07 (2.04-2.10) 8.40 (8.34-8.46) 15.87 (15.79-15.96) Sex Male 4.35 (4.28-4.41) 1.74 (1.70-1.78) 2.81 (2.76-2.86) 2.66 (2.61-2.71) 13.19 (13.08-13.30) 19.16 (19.02-19.29) Female 0.57 (0.55-0.59) 0.77 (0.75-0.80) 0.62 (0.59-0.64) 1.63 (1.59-1.66) 4.57 (4.51-4.63) 13.28 (13.18-13.38) Race/Ethnicity Non-Hispanic White 2.90 (2.86-2.94) 0.99 (0.97-1.02) 1.83 (1.80-1.87) 1.21 (1.18-1.24) 7.80 (7.73-7.87) 15.80 (15.70-15.90) Black 0.65 (0.60-0.71) 3.16 (3.04-3.28) 0.96 (0.89-1.03) 3.82 (3.68-3.96) 10.61 (10.38-10.84) 22.81 (22.47-23.15) American Indian/Alaska Native 1.79 (1.48-2.15) 1.44 (1.15-1.79) 1.47 (1.17-1.81) 3.37 (2.91-3.87) 10.24 (9.44-11.09) 17.97 (16.87-19.11) Asian or Pacific Islander 0.48 (0.43-0.53) 1.27 (1.19-1.34) 0.99 (0.93-1.06) 4.02 (3.88-4.15) 8.62 (8.43-8.82) 12.38 (12.15-12.61) Hispanic 1.35 (1.28-1.42) 0.90 (0.85-0.96) 1.21 (1.15-1.28) 3.84 (3.72-3.96) 9.46 (9.28-9.64) 13.75 (13.53-13.97) EAC = esophageal adenocarcinoma, ESCC = esophageal squamous cell carcinoma, CGC = cardia gastric cancer, NCGC = non-cardia gastric cancer, UGI = upper gastrointestinal tract cancer, CRC = colorectal adenocarcinoma.