Stent insertion for palliation of advanced oesophageal carcinoma symptoms by level of socioeconomic disadvantage in urban New South Wales

To the Editor: For patients with advanced oesophageal carcinoma, palliation of debilitating symptoms such as dysphagia and odynophagia is important for improving quality of life.1 Owing to the possibility of complications, it is generally recommended that stents be used as a palliative measure when expected survival is less than 3 months.2 We analysed linked records from the NSW Central Cancer Registry, the NSW Admitted Patient Data Collection, NSW Registry of Births, Deaths and Marriages death registrations data and Australian Bureau of Statistics mortality data to investigate the association between socioeconomic disadvantage and palliation of advanced (stage IV) oesophageal carcinoma symptoms by stent insertion in urban-dwelling patients in New South Wales, from July 2001 to December 2007. The study was approved by the NSW Population and Health Services Research Ethics Committee.

Of the 479 patients who were diagnosed with primary advanced oesophageal carcinoma before death and for whom linked hospital records were available, 30.3% (145 patients) received stents. The proportion who received stents decreased with increasing disadvantage (P = 0.03 for association; P = 0.003 for trend). After adjustment for patient and tumour characteristics, greater disadvantage remained significantly associated with decreasing odds of stent insertion (Box) (P = 0.02 for association; P = 0.002 for trend). Dysphagia or oesophageal obstruction was reported for some patients and was associated with receiving a stent (χ2 test, P < 0.001) but not associated with level of socioeconomic disadvantage (χ2 test, P = 0.37). As this information is more likely to be reported for those who received a stent, it was not included in the multivariable analysis of association between stenting and socioeconomic disadvantage.

Increased socioeconomic disadvantage has been associated with reduced access to treatment for many cancers.3 Further, research on access to palliative care (generally and for advanced cancer in Australia) has identified barriers such as lack of standardised referral processes and lack of consensus about appropriate timing for access to palliative care.4,5 These factors, plus others that could not be measured reliably or at all from the data we used (such as indication for stenting, patient choice, and use of chemotherapy and radiotherapy), are likely to have contributed to the variation we observed.

For patients with expected survival of less than 3 months, stenting is recommended over alternative treatments such as brachytherapy.2 Because the proportion of patients with less than 3 months between diagnosis and death increased with increasing disadvantage (P = 0.004 for trend), immediate palliation of symptoms by stenting should be a priority for more disadvantaged patients. Later diagnosis for more disadvantaged patients may contribute to the observed variation in stenting, but is at odds with recommended treatment.2 Although patients who die soon after diagnosis may have reduced opportunity to receive a stent, excluding patients who survived 1–2 months after diagnosis made no difference to the findings.

Given the variation in use of stents by level of socioeconomic disadvantage that we observed and the possible role of other factors, further research is required to fully understand patient and health system factors that affect access to palliative care for patients with advanced oesophageal carcinoma. Understanding treatment pathways for more disadvantaged patients should be a priority because stent insertion can provide patients with immediate improvement to quality of life.