Does robotic-assisted esophagectomy improve outcomes compared to other techniques? An NCDB analysis of access and disparities

OBJECTIVE: Surgery remains the gold standard for non-metastatic esophageal cancer. Oncologic resection is considered adequate when 15 regional lymph nodes are sampled and specimen margins are negative. We hypothesize that racial and regional disparities exist in who receives an adequate oncologic resection. METHODS: The National Cancer Database (NCDB) was queried from 2010 to 2021 for patients who underwent esophagectomy for cancer. Exclusion criteria included stage IV disease and incomplete data. Adequate resection was defined as ≥ 15 lymph nodes removed and negative margins. A multivariable regression model identified factors associated with adequate resection, and survival was assessed using Kaplan-Meier curves. RESULTS: 11,451 patients were included. Of these, 5153 (45.0%) had an adequate oncologic resection. Black patients had increased odds of an inadequate resection compared to white patients (OR 1.490, 95%CI 1.227-1.809, p < 0.01). Patients treated at community or comprehensive cancer programs had higher odds of inadequate resection than those treated at academic programs. Medicaid patients had higher odds of an inadequate resection compared to those with private insurance (OR 1.397, 95%CI 1.172-1.664, p = < 0.01), while a minimally invasive esophagectomy (MIE) had 24.0% decreased odds of inadequate resection, and robotic-assisted esophagectomy (RAMIE) had 35.4% decreased odds compared to open surgery (95%CI 0.695-0.830, p < 0.01; 95%CI 0.567-0.735, p < 0.01). Controlling for stage, 5-year survival was higher for patients with an adequate resection. Resection adequacy improved from 38.5% in 2010 to 60.1% in 2021, with increases in MIE and RAMIE. CONCLUSION: Disparities persist in who receives adequate resection for esophageal cancer, though overall resection adequacy has improved, these findings should be interpreted in the context of evolving practice patterns.