A.A. Elkamel1, S. Battan-Wraith1, K.J. Wang1, C. Hsu1, P. Sridhar1, S.G. Worrell1 1University Of Arizona, Cardiothoracic Surgery, Tucson, AZ, USA
Introduction:
Esophageal cancer prevalence is nearly 6.3 per 100 000 population, and the prevalence and mortality rates have steadily increased in the past 20 years. The FLOT and CROSS trials revolutionized peri-operative treatment, but the use of chemotherapy versus radiochemotherapy remains an area of controversey. The aim of this study was to evaluate the real-world impact of XRT in addition to Chemo compared to peri-operative chemotherapy in esophageal adenocarcinoma.
Methods:
The National Cancer Database (NCDB) was queried for patients diagnosed with locally advanced esophageal adenocarcinoma from January 2019 to December 2021. This study investigated patients who received either preoperative multi-agent chemotherapy and radiation versus peri-operative chemotherapy alone. Subgroup analysis of patients that received immunotherapy was also done. The primary clinical outcomes evaluated included length of stay (LOS), 30-day unplanned readmissions, 30- and 90-day mortality rates, and overall survival rate (OSR),. A multivariate logistic regression model was utilized to identify factors associated with these outcomes.
Patients included in this study were at least 18 years old, pretreatment stage cT1N+, M0 or cT2-4a, N0/+, M0 disease. A survival analysis after excluding those who died within 90 days of diagnosis was also performed. This is because patients in peri-operative chemo needed to survive long enough to receive chemo both before and after surgery.
Results:
There were 3,759 patients with esophageal adenocarcinoma who underwent esophagectomy and met inclusion criteria, 3270 (87%) male and a median age of 65. Patients in the perioperative chemotherapy group were younger (p=0.003) with similar co-morbidity score. They were less likely to receive a pCR (16% vs33%, p<0.001). On multivariable analysis controlling for age, Sex, Race/Ethnicity, Insurance, Charlson-Deyo score ≥2, Clinical Stage, Facility type, ypT+ or ypN+ disease, ypT0N0 and year of diagnosis the peri-operative chemotherapy patients had a shorter hospital LOS (p<0.001), were more likely to receive immunotherapy (p<0.001) and had a significantly longer median survival, with a 48% reduction in mortality (hazard ratio: 0.62, 95% CI: 0.42-0.92, p=0.02).
Conclusion:
Perioperative chemotherapy for esophageal adenocarcinoma is associated with improved OS compared to neoadjuvant chemoradiotherapy. The perioperative chemotherapy patients had shorter hospital LOS and were more likely to receive immunotherapy, potentially driving the significant survival advantage. These results are promising as we await the results of peri-operative chemotherapy and immunotherapy trials.