{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T04:17:55Z","timestamp":1782793075779,"version":"3.54.5"},"reference-count":28,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,4,15]],"date-time":"2026-04-15T00:00:00Z","timestamp":1776211200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Background: Disparities in esophageal cancer (EC) outcomes persist, partially due to inequitable access to high-quality surgical care, particularly for socioeconomically disadvantaged populations. This study evaluates the impact of social determinants of health (SDHs) on achieving textbook oncological outcomes (TOOs) and survival in operable EC patients. Methods: Using the National Cancer Database (2010\u20132021), we analyzed 26,367 stage I\u2013IV A esophageal adeno- and squamous cell carcinoma patients undergoing esophagectomy after neoadjuvant chemoradiation. An SDH score (0\u20134) was derived from income, education, rurality, and hospital type. TOOs were defined as R0 resection, \u226520 lymph nodes examined, no 30-day mortality, and no prolonged hospitalization. Multivariable logistic and Cox regression models assessed predictors of TOOs and survival. Results: Overall, 19% achieved TOOs. Median survival time was 6.4 years for TOO+ versus 3.2 years for TOO\u2212. Patients with favorable SDH had longer survival than those with unfavorable SDHs (median 4.0 vs. 3.5 years), but this disparity was largely confined to TOO\u2212 patients. Across stages II\u2013III, low income and treatment at community hospitals were consistently associated with higher mortality among TOO\u2212 patients (HRs ~1.08\u20131.21), whereas SDH factors were largely attenuated among TOO+ patients. Stage-stratified analyses demonstrated that SDH effects were minimal in stage I and IV disease but pronounced in intermediate stages, especially in TOO\u2212 patients. Conclusions: TOOs are a powerful modifier of survival disparities in esophageal cancer. While SDH strongly influences outcomes among patients with suboptimal care pathways, achieving high-quality, textbook oncologic care attenuates these effects. Efforts to improve TOO achievement and expand access to high-quality centers may reduce socioeconomic inequities in survival.<\/jats:p>","DOI":"10.3390\/cancers18081253","type":"journal-article","created":{"date-parts":[[2026,4,15]],"date-time":"2026-04-15T12:25:30Z","timestamp":1776255930000},"page":"1253","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Survival Impact of Textbook Oncological Outcomes and SDHs for Patients with Operable Esophageal Cancer"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1205-2014","authenticated-orcid":false,"given":"Ahmed","family":"Alnajar","sequence":"first","affiliation":[{"name":"DeWitt Daughtry Department of Surgery, University of Miami Health System, Miami, FL 33136, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nestor","family":"Villamizar","sequence":"additional","affiliation":[{"name":"Division of Thoracic Surgery, DeWitt Daughtry Department of Surgery, University of Miami Health System, Miami, FL 33136, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mehmet","family":"Akcin","sequence":"additional","affiliation":[{"name":"DeWitt Daughtry Department of Surgery, University of Miami Health System, Miami, FL 33136, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dao M.","family":"Nguyen","sequence":"additional","affiliation":[{"name":"DeWitt Daughtry Department of Surgery, University of Miami Health System, Miami, FL 33136, USA"},{"name":"Division of Thoracic Surgery, DeWitt Daughtry Department of Surgery, University of Miami Health System, Miami, FL 33136, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diego","family":"Avella-Patino","sequence":"additional","affiliation":[{"name":"DeWitt Daughtry Department of Surgery, University of Miami Health System, Miami, FL 33136, USA"},{"name":"Division of Thoracic Surgery, DeWitt Daughtry Department of Surgery, University of Miami Health System, Miami, FL 33136, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,15]]},"reference":[{"key":"ref_1","first-page":"7","article-title":"Cancer statistics, 2022","volume":"72","author":"Siegel","year":"2022","journal-title":"CA Cancer J. Clin."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"13","DOI":"10.21037\/ccts-23-24","article-title":"Identifying and improving disparities in esophageal cancer care: A narrative review","volume":"6","author":"Tasnim","year":"2024","journal-title":"Curr. Chall. Thorac. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"987","DOI":"10.1016\/j.xjon.2023.09.006","article-title":"The impact of refusing esophagectomy for treatment of locally advanced esophageal adenocarcinoma","volume":"16","author":"Wong","year":"2023","journal-title":"JTCVS Open"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1604","DOI":"10.1016\/j.jtcvs.2024.11.008","article-title":"Textbook outcome after robotic and laparoscopic Ivor Lewis esophagectomy is associated with improved survival: A propensity score\u2013matched analysis","volume":"169","author":"Seika","year":"2025","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"743","DOI":"10.1097\/SLA.0000000000001702","article-title":"Traveling to a High-volume Center is Associated with Improved Survival for Patients with Esophageal Cancer","volume":"265","author":"Speicher","year":"2017","journal-title":"Ann. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1134","DOI":"10.1016\/j.athoracsur.2020.09.035","article-title":"The Association of Textbook Outcome and Long-Term Survival After Esophagectomy for Esophageal Cancer","volume":"112","author":"Kalff","year":"2021","journal-title":"Ann. Thorac. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"742","DOI":"10.1002\/bjs.10486","article-title":"Textbook outcome as a composite measure in oesophagogastric cancer surgery","volume":"104","author":"Busweiler","year":"2017","journal-title":"Br. J. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1014","DOI":"10.1002\/jso.26606","article-title":"Socioeconomic factors in timing of esophagectomy and association with outcomes","volume":"124","author":"Chen","year":"2021","journal-title":"J. Surg. Oncol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"doaa006","DOI":"10.1093\/dote\/doaa006","article-title":"Accessing surgical care for esophageal cancer: Patient travel patterns to reach higher volume center","volume":"33","author":"Diaz","year":"2020","journal-title":"Dis. Esophagus"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Vedire, Y., Rana, N., Groman, A., Siromoni, B., Yendamuri, S., and Mukherjee, S. (2023). Geographical Disparities in Esophageal Cancer Incidence and Mortality in the United States. Healthcare, 11.","DOI":"10.3390\/healthcare11050685"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1001\/jamasurg.2024.5009","article-title":"Travel to High-Volume Centers and Survival After Esophagectomy for Cancer","volume":"160","author":"Sakowitz","year":"2025","journal-title":"JAMA Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"393","DOI":"10.6004\/jnccn.2023.0019","article-title":"Esophageal and Esophagogastric Junction Cancers, Version 2.2023, NCCN Clinical Practice Guidelines in Oncology","volume":"21","author":"Ajani","year":"2023","journal-title":"J. Natl. Compr. Cancer Netw."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"350","DOI":"10.1016\/j.surg.2024.03.032","article-title":"Textbook outcome after esophagectomy: A retrospective study from a high-volume center","volume":"176","author":"Mathiesen","year":"2024","journal-title":"Surgery"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"doab011","DOI":"10.1093\/dote\/doab011","article-title":"Textbook outcome for esophageal cancer surgery: An international consensus-based update of a quality measure","volume":"34","author":"Kalff","year":"2021","journal-title":"Dis. Esophagus"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"888","DOI":"10.1016\/j.xjon.2023.09.013","article-title":"The impact of social determinants of health on textbook oncological outcomes and overall survival in locally advanced non-small cell lung cancer","volume":"16","author":"Alnajar","year":"2023","journal-title":"JTCVS Open"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"548","DOI":"10.1016\/j.atssr.2023.05.020","article-title":"Social Determinants of Health Impact on Survival of Patients with Malignant Pleural Mesothelioma","volume":"1","author":"Alnajar","year":"2023","journal-title":"Ann. Thorac. Surg. Short. Rep."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Alnajar, A., Collier, A., Akcin, M., Lew, J.I., and Vaghaiwalla, T.M. (2025). Centralized Surgical Care Improves Survival in Non-Functional Well-Differentiated Pancreatic Neuroendocrine Tumors. Cancers, 17.","DOI":"10.3390\/cancers17183030"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1002\/jso.70143","article-title":"Higher Composite Social Determinants of Health Scores Are Associated with Worse Survival in Patients with Small Bowel Neuroendocrine Tumors","volume":"133","author":"Alnajar","year":"2026","journal-title":"J. Surg. Oncol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1016\/j.ejso.2012.10.007","article-title":"Focusing on desired outcomes of care after colon cancer resections; hospital variations in \u2018textbook outcome\u2019","volume":"39","author":"Kolfschoten","year":"2013","journal-title":"Eur. J. Surg. Oncol. (EJSO)"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1578","DOI":"10.1007\/s11605-023-05690-0","article-title":"Textbook Outcome in Bariatric Surgery: Evolution During 15 Years in a Referral Center","volume":"27","author":"Villodre","year":"2023","journal-title":"J. Gastrointest. Surg."},{"key":"ref_21","first-page":"11","article-title":"Social Determinants of Health and Cancer Survivorship","volume":"7","author":"Coughlin","year":"2021","journal-title":"J. Environ. Health Sci."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"7186","DOI":"10.1002\/cam4.2595","article-title":"Socioeconomic disparities in timeliness of care and outcomes for anal cancer patients","volume":"8","author":"Ahmad","year":"2019","journal-title":"Cancer Med."},{"key":"ref_23","first-page":"78","article-title":"Cancer disparities by race\/ethnicity and socioeconomic status","volume":"54","author":"Ward","year":"2004","journal-title":"CA Cancer J. Clin."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1002\/ags3.12799","article-title":"Textbook outcome contributes to long-term prognosis in elderly patients with esophageal squamous cell carcinoma","volume":"8","author":"Matsumoto","year":"2024","journal-title":"Ann. Gastroenterol. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2074","DOI":"10.1056\/NEJMoa1112088","article-title":"Preoperative Chemoradiotherapy for Esophageal or Junctional Cancer","volume":"366","author":"Hulshof","year":"2012","journal-title":"N. Engl. J. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"doy020","DOI":"10.1093\/dote\/doy020","article-title":"Disparities in survival after trimodality therapy for esophageal adenocarcinoma","volume":"31","author":"Eng","year":"2018","journal-title":"Dis. Esophagus"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1097\/SLA.0000000000005782","article-title":"Robotic Versus Con-ventional Minimally Invasive Esophagectomy for Esophageal Cancer: A Meta-analysis","volume":"278","author":"Zhang","year":"2023","journal-title":"Ann. Surg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e312","DOI":"10.37765\/ajmc.2020.88504","article-title":"Social determinants of health score: Does it help identify those at higher cardiovascular risk?","volume":"26","author":"Palacio","year":"2020","journal-title":"Am. J. Manag. 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