Socioeconomic Disparities in the Progression of GERD and Barrett’s Esophagus to Esophageal Adenocarcinoma

Objective: To assess the impact of socioeconomic and other factors on progression from gastroesophageal reflux disease (GERD) and Barrett’s esophagus (BE) to esophageal adenocarcinoma (EAC). Summary Background Data: Socioeconomic 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, healthcare utilization, health literacy and other competing social determinants of health that vary with SES. Methods: Patients 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. Results: Among 162,542 GERD patients, 7,604 (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 (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 per 1,000 vs. 10 per 1,000, P <0.0001) or diagnosed with BE (4 per 1,000 vs. 50 per 1,000, P <0.0001). They were also more likely to be diagnosed with early-onset EAC (13 per 1,000 vs. 5 per 1,000, 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). Conclusion: Low 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 healthcare 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.