Definitive or Preoperative Chemoradiation Therapy for Esophageal Cancer: Patterns of Care and Survival Outcomes

Abstract

The optimal management of patients with localized esophageal cancer is uncertain. The objective of this study was to analyze contemporary patterns of care for esophageal cancer using the National Cancer Database. Patients diagnosed with localized esophageal adenocarcinoma or squamous cell carcinoma from 2004 to 2011 and who received preoperative chemoradiation therapy, followed by esophagectomy (trimodality), or definitive chemoradiation therapy were identified in the National Cancer Database. Only patients who received a radiation dose between 41.4 and 64.8 Gy were included. Kaplan-Meier, Cox regression, and propensity score-matched survival analyses were performed to compare overall survival between those receiving chemoradiation therapy vs trimodality therapy. There were 8,064 patients, of whom 44.9% received trimodality therapy and 55.1% chemoradiation therapy. Trimodality therapy was associated with improved overall survival (p < 0.001), with a median overall survival of 35.6 months and 3-year overall survival of 49.6%, whereas for patients receiving chemoradiation therapy, median and 3-year overall survival were 16.8 months and 26.8%, respectively. For patients receiving chemoradiation therapy, dose escalation beyond 50.4 Gy was used 35.9% of the time but was not associated with an improvement in overall survival over those receiving 50 Gy (p= 0.62). The survival benefit of trimodality therapy remained after propensity score-matched analysis. Definitive chemoradiation therapy is more commonly used than trimodality therapy, but trimodality treatment is associated with excellent survival outcomes on propensity-matched and unmatched survival analysis. Dose escalation beyond 50 Gy remains frequently used but is not associated with a survival benefit.