br Department of Surgery University
1. Department of Surgery, University of Colorado at Denver, Aurora, Colorado
2. Department of Cardiothoracic Surgery, University of Colorado at Denver, Aurora, Colorado
3. Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, Colorado 4. Department of Anesthesiology, University of New York at Buffalo, Buffalo, New York
Address for Correspondence:
Csaba Gajdos, MD, Department of Surgery, University of Buffalo, Buffalo NY
VA Western NY Healthcare System, 3495 Bailey Avenue, Rm 503C, Buffalo NY 14215 Email: [email protected]; [email protected]
Short Title: Survival in Esophageal Cancer
Background: Esophageal squamous cell carcinoma (ESCC) has been poorly studied, approached with therapeutic nihilism and likely undertreated. We studied the impact of clinical and patient factors on the survival of ESCC in the US.
Methods: We selected patients with Stage I-III ESCC from 2004 to 2013 using the National Cancer Database (NCDB). Patients were categorized into the following treatment modalities: (1) definitive chemoradiation (CR), (2) neoadjuvant therapy followed by esophageal resection (ER), (3) ER alone, and (4) ER followed by adjuvant therapy. Our main outcome measure was overall survival.
Results: We identified 11,229 patients with ESCC undergoing definitive CR (78.6%), neoadjuvant therapy followed by ER (8.5%), ER alone (10.1%), and ER followed by adjuvant therapy (2.6%). Compared to neoadjuvant therapy, both ER alone and definitive CR were associated with significantly increased mortality. Patients treated at high volume centers (>20), regardless of whether they underwent ER, had improved survival compared to facilities performing 10-19, 5-9, and <5 ER per year. Conclusions: Patients treated at high-volume facilities were more likely to receive neoadjuvant therapy and there was a significant inverse relationship between annual surgical volume and long-term survival for both surgically and non-surgically treated Stage I-III ESCC patients.
Key words: esophagus, squamous cell carcinoma, neoadjuvant therapy, survival
Esophageal cancer (EC) makes up 1% of all cancers diagnosed in the United States. In 2017, it Melatonin is estimated that 16,940 new cases of esophageal cancer will be diagnosed and 15,690 patients will die from EC in the United States (1). Histologically, the most common subtypes of EC can be categorized as squamous cell carcinoma (ESCC) or adenocarcinoma. Historically, ESCCs accounted for great majority of ECs in Western countries (2). However, in recent years, the incidence of ESCC has decreased significantly. In the SEER database from 2009-2013, only 33% of all patients with invasive EC had ESCC compared to 62% of patients having adenocarcinoma (3).
ESCC is clinically staged according to the Tumor Node Metastases (TNM) staging system of the American Joint Committee on Cancer. Staging is further subdivided based upon tumor location (upper, middle, lower esophagus) and the grade of the tumor cells (4, 5). ESCC frequently presents in the upper esophagus and is often diagnosed in patients with poor medical condition with multiple risk factors for surgery. Secondary to these risk factors many of these patients are approached with therapeutic nihilism and could be significantly undertreated. Randomized controlled trials comparing different treatment modalities for EC have shown inconsistent results and are limited by mixing patients with adeno and squamous cell carcinoma.
The purpose of this study is to evaluate utilization of surgical therapy and the impact of clinical and patient factors on overall survival using a large national database of patients with ESCC within the United States.
Material and Methods
Using the National Cancer Data Base (NCDB), we performed a retrospective cohort study of all patients with ESCC between 2004 and 2013. Each facility within the NCDB is assigned to a cancer program category based on the facility or organization type, services provided, and newly diagnosed and treated cancer cases per year, i.e., Community Cancer Program (CCP); Comprehensive Community Cancer Program (CCCP); Academic Cancer Program (ACP); and Integrated Network
Cancer Program (INCP). The University of Colorado institutional review board stated that no official waiver was needed since no patient, physician or hospital identifiers were examined.
distance from incisors to proximal tumor edge (0-19 cm, 20-29 cm, ³30 cm) were collected. Program volume status was defined according to the total number of esophagectomies performed for all