Surgery in Locally Advanced Esophageal Adenocarcinoma for Patients of Advanced Age or Significant Comorbidities

Abstract

<h3>Purpose/Objective(s)</h3> The addition of surgery to chemoradiation (CRT) for esophageal adenocarcinoma has shown improved overall survival (OS) in many retrospective studies but has not demonstrated improved OS in randomized trials. Patients with comorbidities or advanced age are more likely to be given definitive CRT without surgery. Using the National Cancer Database (NCDB), we aim to identify if there is medical equipoise between trimodality therapy (TMT) with neoadjuvant CRT compared to definitive CRT for patients with locally advanced esophageal adenocarcinoma with advanced age or with significant comorbidities. <h3>Materials/Methods</h3> The NCDB was queried for patients with stage II-III esophageal adenocarcinoma who received either definitive CRT, or neoadjuvant CRT followed by surgery. Patients under 18 years old, with T4 disease, or who received under 4140 cGy were excluded. Bivariate analysis was used to assess the association between patient characteristics and treatment groups (TMT or definitive CRT). Log-rank tests and Cox proportional hazards models were performed to assess for differences in survival. <i>P</i>-value significance was set to < 0.05. <h3>Results</h3> A total of 14,945 patients met the inclusion criteria. Median age in the TMT and definitive CRT groups was 63 years vs 70 years, while Charlson/Deyo comorbidity condition (CDCC) score was ≥3 in 1.6% vs 2.8%, respectively. TMT was associated with improved survival in patients < 50, 50-60, 61-70, 71-80, and 81-90 years old (<i>P</i> < 0.05 for all). In patients 81-90 years old, 2-year OS was 39.7% vs 27.9% (<i>P</i> = 0.0065). TMT was also associated with significantly improved survival in patients with a CDCC score of 0, 1, 2 and ≥3 (<i>P</i> < 0.05 for all). In patients with a CDCC score ≥3, 2-year OS was 53.3 vs 29.7% (<i>P</i> = 0.0002). Nearly all sub-groups of sex, facility type, income, insurance, primary site, histology, T stage, N stage, and group stage also had significantly improved OS with TMT. Only patients with primary tumors in the upper third of the esophagus (<i>P</i> = 0.3633) or with a T stage of 1B (<i>P</i> = 0.0694) did not have a significant OS benefit with TMT. <h3>Conclusion</h3> No single analyzed characteristic was associated with a lack of OS benefit from TMT compared to definitive CRT, including age > 80 years old and CDCC score ≥3. This suggests that TMT should be offered to patients who can tolerate it, and that caution and clinical judgment should be used when considering the omission of surgery in locally advanced esophageal adenocarcinoma.