Socioeconomic Disparities in the Progression of Gastroesophageal Reflux Disease and Barrett's Esophagus to Esophageal Adenocarcinoma.

objectiveTo assess the impact of socioeconomic and other factors on progression from gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE) to esophageal adenocarcinoma (EAC).

backgroundSocioeconomic status (SES) influences outcomes in EAC, but its role in the progression from GERD and BE to EAC is not well-defined. Risk of progression may be influenced by access and engagement with endoscopic screening and surveillance, health care utilization, health literacy, and other competing social determinants of health that vary with SES.

methodsPatients diagnosed with GERD between 2015 and 2023 across a regional network of 14 hospitals and >300 clinics were reviewed for BE and EAC. U.S. Census data on wealth, income, education and occupation were used to categorize patients into low, middle, and high SES groups. Univariate and multivariable analyses were conducted to evaluate the influence of demographic, clinical, and SES factors on progression to EAC from GERD and BE.

resultsAmong 162,542 patients with GERD, 7604 (4.70%) developed BE and 331 (0.20%) progressed to EAC. Unemployment, disability, lack of college education, and high school non-graduation were associated with progression to EAC (all P < 0.0001). Independent predictors of disease progression included established demographic and clinical factors (all P < 0.0001), lack of private insurance (odds ratio [OR]: 1.4, P < 0.0001), and low SES (OR: 1.6, P < 0.0001). For BE to EAC progression, predictors were similar, including lack of private insurance (OR: 2.0, P = 0.015) and low SES (OR: 2.0, P = 0.028). Patients with low SES were less frequently endoscopically evaluated (4/1000 vs 10/1000, P < 0.0001) or diagnosed with BE (4/1000 vs 50/1000, P < 0.0001). They were also more likely to be diagnosed with early-onset EAC (13/1000 vs 5/1000, P = 0.0138) and metastatic EAC (77.4% vs 53.1%, P = 0.001). Among patients with BE, those with low SES had a higher rate of progression to EAC (1.77% vs 0.95%, P = 0.026).

conclusionsLow SES is associated with increased progression to EAC, with higher rates of early-onset and metastatic disease at diagnosis. Disparities in access to endoscopic screening and surveillance play a significant role, compounded by socioeconomic barriers such as limited health care engagement and competing social priorities. Integrating SES into risk stratification models alongside clinical factors is essential for improving early detection and reducing the burden of advanced disease.