Abstract
In this issue of Volume 3 of Foregut, we address a topic which has always been relevant to our practice of medicine and surgery, but which gained significantly more attention during the recent COVID-19 pandemic—disparities. Looking at both benign and malignant foregut diseases, we can categorize the 2 disparate areas in this issue into: (1) differences in healthcare delivery and how it impacts diagnoses, interventions, and outcomes for foregut diseases and (2) biologic differences between sexes and races for various esophagogastric diseases.
Per the Constitution of the World Health Organization, enjoyment of the highest attainable standard of health is a fundamental right of every human being regardless of race, religion, political belief, economic or social condition. 1
Disparities in healthcare delivery can be explained by several factors but significantly by systemic and socioeconomic differences that are avoidable and unjust. 2 In his contribution, Park 3 reviews racial and ethnic differences in the management of benign esophageal disorders and notes that there is not much data out there. He concludes we need to address access to care for under-represented minorities including collecting social determinants of health (SDOH) to understand more about the barriers to diagnosing and treating GERD and achalasia for example but also to learn more about epidemiologic aspects. Research has shown that health is shaped by more than just quality healthcare, but also by social and environmental factors known collectively as the SDOH. We know that for many, the root causes of medical issues are a lack of employment, income, stable housing or food, and limited education. These challenges can contribute to chronic disease and mental health issues and create barriers to accessing healthcare.
Compared with benign disease, we know more about esophageal cancer disparities including stage at time of diagnosis and rates of intervention and subsequent outcomes. Salami and Rao 4 summarize these areas in their review of sex, racial, and ethnic differences in Barrett’s esophagus and esophageal adenocarcinoma. Black patients do worse overall than non-Hispanic whites, Asians, and Hispanics. Potential explanations include both provider and patient-level factors but also as Parikh and colleagues5 conclude socioeconomic differences access to care, lack of awareness, diets low in fruits and vegetables, and higher rates of smoking and alcohol use.
Continuing on the topic of socioeconomic barriers, Wang and Dowell review precision oncology in foregut malignancies and find that somatic tumor testing and access to targeted and immunotherapy is limited in the high poverty groups. 6 The authors also report inequity in delivery of care based on workplace discrimination and financial limitations in paying for the treatments.
Regarding the biology of the diseases, this issue also includes the contribution by Wilkerson et al 7 about hiatal hernias—the female predominance in the epidemiology of hiatal hernias especially after hormonal changes of pregnancy and in the kyphotic elderly women. Kassamali and Lin 8 educate us about gastroparesis and higher prevalence in females and provides some possible theories and explanations for why women experience more nausea, early satiety and hospitalizations for these symptoms.
To operationalize equity, you must first recognize it. With regards to healthcare delivery, the take home message from these reviews is that more work needs to be done to reduce the disparity gap. Some social barriers preclude delivery of equitable care as well as prevent research in this space to achieve health equity. Actionable items include capturing SDOH in large databases, engaging community leaders to improve access for patient education, and assisting with de-stigmatization of clinical trial enrollment, as well as working with primary care providers to recognize the value of early referral to specialists for prompt diagnosis of serious pathology.
Thank you to the contributors of the invited reviews as well as the original research authors. We continue to receive in increasing volume of interesting papers as we move forward with Foregut in this third year. 9 Please enjoy the current content, use it as a resource for preparing hypotheses and writing methods for esophageal research, and submit to our journal!