Survival Impact of Textbook Oncological Outcomes and SDHs for Patients with Operable Esophageal Cancer

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 (2010-2021), we analyzed 26,367 stage I-IV A esophageal adeno- and squamous cell carcinoma patients undergoing esophagectomy after neoadjuvant chemoradiation. An SDH score (0-4) was derived from income, education, rurality, and hospital type. TOOs were defined as R0 resection, ≥20 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-. 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- patients. Across stages II-III, low income and treatment at community hospitals were consistently associated with higher mortality among TOO- patients (HRs ~1.08-1.21), 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- 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.