Effect of histologic subtype on treatment and outcomes for esophageal cancer in the United States

Nomograms to predict survival rates for esophageal cancer patients with malignant behaviors based on ICD-0-3

AIM

We aimed to investigate the effect of current treatment based on stage and histology type, which were important factors for treating esophageal cancer.

METHODS

Log-rank test, COX and nomograms were used for survival analysis. DCA, C-index and calibration curves were used for validation.

RESULTS

A total of 3224 patients were recruited. As for cT2-T4aM0 patients, chemotherapy and radiation prolonged overall survival (OS) for esophageal squamous cell carcinoma (ESCC) and chemotherapy improved OS for esophageal adenocarcinoma (EAC). Meanwhile, neoadjuvant radiotherapy had longer OS than adjuvant radiotherapy for ESCC. As for T4b patients, radiation and chemotherapy correlated with better OS for ESCC and chemotherapy prolonged OS for EAC.

CONCLUSION

Neoadjuvant radiotherapy might be optimal for cT2-T4aM0 ESCC. Radiation was recommended for T4b ESCC while chemotherapy was recommended for T4b EAC.

Definitive chemoradiation or surgery in elderly patients with potentially curable esophageal cancer in the Netherlands: a nationwide population-based study on patterns of care and survival

BACKGROUND

The aim of our study was to describe treatment patterns and the impact on overall survival among elderly patients (75 years and older) with potentially curable esophageal cancer.

MATERIAL AND METHODS

Between 2003 and 2013, 13,244 patients from the nationwide population-based Netherlands Cancer Registry (NCR) were diagnosed with potentially curable esophageal cancer (cT2-3, X, any cN, cM0, X) of which 34% were elderly patients (n = 4501).

RESULTS

Surgical treatment with or without neoadjuvant treatment remained stable among elderly patients (around the 16% between 2003 and 2013). However, among younger patients, surgical treatment increased from 60.2 to 67.0%. The use of definitive chemoradiation (dCRT) increased in elderly patients from 1.9 to 19.5% and in younger patients from 5.2 to 17.2%. Due to the increase in dCRT, treatment with curative intent doubled in the elderly from 17 to 37.1%. Multivariable Cox regression revealed that elderly patients with an adenocarcinoma receiving surgery alone or dCRT had a significantly worse overall survival compared to those receiving surgery with neoadjuvant chemo (radio) therapy (nCRT/CT) (HR: 1.7 95% CI 1.4-2.0 and HR: 1.9 95% CI 1.5-2.3). However, among elderly with squamous cell carcinoma overall survival was comparable between dCRT, surgery alone and surgery with nCRT/CT.

CONCLUSIONS

Survival was comparable among elderly patients with squamous cell carcinoma who underwent surgery with nCRT/CT, surgery alone or received dCRT, while elderly patients with an adenocarcinoma who underwent surgery with nCRT/CT had a better overall survival when compared with surgery alone or dCRT. Therefore, dCRT can be considered as a reasonable alternative for surgery among potentially curable elderly patients with esophageal squamous cell carcinoma. However, in elderly patients with esophageal adenocarcinoma surgery with nCRT/CT is still preferable regarding overall survival.

Treatment of esophagogastric junction carcinoma: An unsolved debate

The incidence of esophagogastric junction adenocarcinoma (AEG) is increasing worldwide. Barrett’s esophagus (BE) associated with dysplasia is the main risk factor for the development of cancer. Currently, screening programs to individuate and eradicate BE represent the best way to reduce AEG cancer. Several endoscopic approaches are here discussed. Surgical strategies for different types of AEG cancer are now fairly standardized, and multidisciplinary strategies using chemotherapy or chemoradiotherapy may improve the outcome of these patients. Here we briefly discuss the keypoints, main topics, and critical issues, according to accumulating evidence and taking into account our own experience.

Clinical-pathological characteristics and prognosis of a cohort of oesophageal cancer patients: a competing risks survival analysis

BACKGROUND

To determine the clinical course, follow-up strategies, and survival of oesophageal cancer patients using a competing risks survival analysis.

METHODS

We conducted a retrospective and prospective follow-up study. The study included 180 patients with a pathological diagnosis of oesophageal cancer in A Coruña, Spain, between 2003 and 2008. The Kaplan-Meier methodology and competing risks survival analysis were used to calculate the specific survival rate. The study was approved by the Ethics Review Board (code 2011/372, CEIC Galicia).

RESULTS

The specific survival rate at the first, third, and fifth years was 40.2%, 18.1%, and 12.4%, respectively. Using the Kaplan-Meier methodology, the survival rate was slightly higher after the third year of follow-up. In the multivariate analysis, poor prognosis factors were female sex (hazard ratio [HR] 1.94; 95% confidence interval [CI], 1.24-3.03), Charlson's comorbidity index (HR 1.17; 95% CI, 1.02-1.33), and stage IV tumours (HR 1.70; 95% CI, 1.11-2.59). The probability of dying decreased with surgical and oncological treatment (chemotherapy and/or radiotherapy) (HR 0.23; 95% CI, 0.12-0.45). The number of hospital consultations per year during the follow-up period, from diagnosis to the appearance of a new event (local recurrences, newly appeared metastasis, and newly appeared neoplasias) did not affect the probability of survival (HR 1.03; 95% CI, 0.92-1.15).

CONCLUSIONS

The Kaplan-Meier methodology overestimates the survival rate in comparison to competing risks analysis. The variables associated with a poor prognosis are female sex, Charlson's comorbidity score and extensive tumour invasion. Type of follow-up strategy employed after diagnosis does not affect the prognosis of the disease.

Hospital of diagnosis and probability to receive a curative treatment for oesophageal cancer

BACKGROUND

Surgical treatment of oesophageal cancer in the Netherland is performed in high volume centres. However, the decision to refer patients for curative surgery is made in the referring hospital of diagnosis. The objective of this study was to determine the influence of hospital of diagnosis on the probability of receiving a curative treatment and survival.

MATERIAL AND METHOD

All patients with resectable oesophageal cancer (cT1-3, cN0-3, cM0-1A) diagnosed between 2003 and 2010 (n = 849) were selected from the population-based Eindhoven Cancer Registry, an area with ten non-academic hospitals. Multivariate logistic regression analysis was conducted to examine the independent influence of hospital of diagnosis on the probability to receive curative treatment. Furthermore, the effect of hospital of diagnosis on overall survival was examined using multivariate Cox regression analysis.

RESULTS

849 patients were included in the study. A difference in proportion of patients referred for surgery was observed ranging from 33% to 67% (p = 0.002) between hospitals of diagnosis. Multivariate logistic regression analysis confirmed the effect of hospital of diagnosis on the chance of undergo curative treatment (OR 0.1, 95% CI 0.1-0.4). Multivariate Cox regression analysis showed that hospital of diagnosis also had an effect on overall survival, up to hazard ratio (HR) 2.2 (95% CI 1.3-3.7).

CONCLUSION

There is a strong relation between hospital of diagnosis and the chance of referring patients with oesophageal cancer for a curative treatment as well as overall survival. Patients diagnosed with oesophageal cancer should be discussed within a regional multidisciplinary expert panel.

Systematic review and meta-analysis of tumor biomarkers in predicting prognosis in esophageal cancer

BACKGROUND

Esophageal cancer (EC) is a frequently occurring cancer with poor prognosis despite combined therapeutic strategies. Many biomarkers have been proposed as predictors of adverse events. We sought to assess the prognostic value of biomarkers in predicting the overall survival of esophageal cancer and to help guide personalized cancer treatment to give patients the best chance at remission.

METHODS

We conducted a systematic review and meta-analysis of the published literature to summarize evidence for the discriminatory ability of prognostic biomarkers for esophageal cancer. Relevant literature was identified using the PubMed database on April 11, 2012, and conformed to the REMARK criteria. The primary endpoint was overall survival and data were synthesized with hazard ratios (HRs).

RESULTS

We included 109 studies, exploring 13 different biomarkers, which were subjected to quantitative meta-analysis. Promising markers that emerged for the prediction of overall survival in esophageal squamous cell cancer included VEGF (18 eligible studies, n=1476, HR=1.85, 95% CI, 1.55-2.21), cyclin D1 (12 eligible studies, n=1476, HR=1.82, 95% CI, 1.50-2.20), Ki-67 (3 eligible studies, n=308, HR=1.11, 95% CI, 0.70-1.78) and squamous cell carcinoma antigen (5 eligible studies, n=700, HR=1.28, 95% CI, 0.97-1.69); prognostic markers for esophageal adenocarcinoma included COX-2 (2 eligible studies, n=235, HR=3.06, 95% CI, 2.01-4.65) and HER-2 (3 eligible studies, n=291, HR=2.15, 95% CI, 1.39-3.33); prognostic markers for uncategorized ECs included p21 (9 eligible studies, n=858, HR=1.27, 95% CI, 0.75-2.16), p53 (31 eligible studies, n=2851, HR=1.34, 95% CI, 1.21-1.48), CRP (8 eligible studies, n=1382, HR=2.65, 95% CI, 1.64-4.27) and hemoglobin (5 eligible studies, n=544, HR=0.91, 95% CI, 0.83-1.00).

CONCLUSIONS

Although some modest bias cannot be excluded, this review supports the involvement of biomarkers to be associated with EC overall survival.

Comparison of the surgical treatment strategies for Siewert type II squamous cell carcinoma in the same area as esophagogastric junction carcinoma: data from a single Japanese high-volume cancer center

Purpose

Siewert type II esophagogastric junction adenocarcinoma (ADC) and squamous cell carcinoma (SCC) existing in the same area have distinct clinicopathological characteristics. The objective of this study was to examine differences in the surgical treatment and survival data, according to the histological subtype, in a single high-volume cancer center.

Methods

We retrospectively examined data from a total of 123 patients. Seventy-two patients with Siewert type II ADC and 51 patients with SCC in the same area.

Results

In terms of the clinicopathological factors, the SCC patients had more advanced stage disease and thoracotomy was more frequently performed than in the ADC patients. The 5-year overall survival (OS) rates did not differ significantly between SCC and ADC, regardless of whether or not mediastinal, splenic hilum and para-aortic lymph node dissection was performed. Based on the calculated index for the frequency of nodal metastasis and the five-year OS rate for involvement at each level, only node nos. 1, 2, 3 and 7 had a high index (>5) in both groups. The multivariate Cox regression analysis showed that only age (<65), the pN category and residual tumor classification were independently associated with the outcome.

Conclusions

Differences in the histological type of esophagogastric junction cancer were not independent prognostic factors for survival, and there appears to be a benefit to dissecting the number 1, 2, 3 and 7 lymph nodes.

Surgery is an essential component of multimodality therapy for patients with locally advanced esophageal adenocarcinoma

BACKGROUND

Experience with neoadjuvant chemoradiation (CXRT) has raised questions regarding the additional benefit of surgery after locally advanced esophageal adenocarcinoma patients achieve a clinical response to CXRT. We sought to quantify the value of surgery by comparing the overall (OS) and disease-free survival (DFS) of trimodality-eligible patients treated with definitive CXRT vs. CXRT followed by esophagectomy.

METHODS

We identified 143 clinical stage III esophageal adenocarcinoma patients that were eligible for trimodality therapy. All patients successfully completed neoadjuvant CXRT and were considered appropriate candidates for resection. Patients that were medically inoperable were excluded. Cox regression models were used to identify significant predictors of survival.

RESULTS

Among the 143 patients eligible for surgery after completing CXRT, 114 underwent resection and 29 did not. Poorly differentiated tumors (HR = 2.041, 95% CI = 1.235-3.373) and surgical resection (HR = 0.504, 95% CI = 0.283-0.899) were the only independent predictors of OS. Patients treated with surgery had a 50 and 54 % risk reduction in overall and cancer-specific mortality, respectively. Median OS (41.2 vs. 20.3 months, p = 0.012) and DFS (21.5 vs. 11.4 months, p = 0.007) were significantly improved with the addition of surgery compared to definitive CXRT.

CONCLUSIONS

Surgery provides a significant survival benefit to trimodality-eligible esophageal adenocarcinoma patients with locally advanced disease.

Utilization of surgery in trimodality-eligible patients with locally advanced esophageal adenocarcinoma in a nonprotocol setting

Trimodality therapy with neoadjuvant chemoradiation followed by surgery significantly improves the survival of locally advanced (clinical stage IIA-III) esophageal cancer patients compared to treatment with surgery alone. This has resulted in an increased use of neoadjuvant therapy in recent years, yet little is known regarding how this increase has impacted the utilization of surgery in the treatment of locally advanced disease. Although previous reports of experimental protocols suggest that 90-95% of patients complete trimodality therapy including a surgical resection, trimodality therapy completion among adenocarcinoma patients eligible for curative resection has not been evaluated in a nonprotocol setting. We sought to (i) assess the completion of trimodality therapy among locally advanced esophageal adenocarcinoma patients; (ii) characterize the reasons for avoiding surgery; and (iii) identify factors associated with failure to complete trimodality therapy. We identified 296 patients with locally advanced esophageal adenocarcinoma eligible for trimodality therapy at our institution. All patients were evaluated in a multidisciplinary setting and considered eligible for curative resection after initial staging and physiologic assessment. Multivariable logistic regression was used to identify factors associated with failure to complete trimodality therapy. Of 296 trimodality-eligible patients, 33% (97/296) did not complete trimodality therapy. Reasons for not undergoing surgery included patient choice (27.8%, 27/97), distant progression of disease during chemoradiation (23.7%, 23/97), and physician preference for surveillance (23.7%, 23/97). In addition, 17.5% (17/97) of patients had physical deterioration in performance status, and treatment-related deaths occurred in 7.2% (7/97) prior to surgery. In the total study population (n = 296), multivariable logistic regression identified older age (≥70 years: odds ratio [OR] = 6.611, 95% confidence interval [CI]: 2.900-15.071), pretreatment standard uptake value (6.8-10.1: OR = 2.393, 95% CI: 1.050-5.455; ≥15.8: OR = 3.623, 95% CI: 1.604-8.186), and a radiation dose of 50.4 Gy (OR = 5.312, 95% CI: 2.365-11.929) as being significantly associated with failure to complete trimodality therapy. Among the subgroup of patients that successfully completed chemoradiation (n = 266), older patients (≥70 years: OR = 9.606, 95% CI: 3.637-25.372), those with a comorbidity score of 2 or higher (OR = 4.059, 95% CI: 1.257-13.103), and those that received a radiation dose of 50.4 Gy (OR = 4.878, 95% CI: 1.974-12.054) were at a significantly higher risk of not completing trimodality therapy. Trimodality therapy completion among patients with locally advanced esophageal adenocarcinoma in a nonprotocol setting is considerably lower than what has previously been reported in clinical trials. Our findings suggest that a selective approach to surgery is commonly utilized in clinical practice. Trimodality-eligible patients that are older and have a higher comorbidity score are at risk for not completing trimodality therapy.

Racial disparities in esophageal cancer outcomes

BACKGROUND

Racial disparities in outcomes have been documented among patients with esophageal cancer. The purpose of this study is to identify mechanisms for ethnicity/race-related differences in the use of cancer-directed surgery and mortality.

METHODS

Data from the Surveillance, Epidemiology and End Results (SEER) program were used to evaluate non-Hispanic black, non-Hispanic white and Hispanic patients diagnosed with non-metastatic esophageal cancer (squamous cell carcinoma or adenocarcinoma) from 2003-2008. Age, marital status, stage, histology and location were examined as predictors of receipt of surgery and mortality in multivariate analyses.

RESULTS

A total of 6,737 patient files (84 % white, 10 % black, 6 % Hispanic) were analyzed. Black and Hispanic patients were more likely than whites to have squamous cell carcinoma (86 vs. 41 vs. 26 %, respectively; p < 0.001) and lesions in the midesophagus (58 vs. 38 vs. 26 %, respectively; p < 0.001). Blacks and Hispanics were less likely to undergo esophagectomy (adjusted odds ratio 0.48, 95 % confidence interval (CI) 0.39-0.60 and 0.71, 95 % CI 0.56-0.90]. We noted significant variations in esophagectomy rates among patients with midesophageal cancers; 15 % of blacks underwent esophagectomy compared to 22 % of Hispanics and 29 % of whites (p < 0.001). Black and Hispanic patients had a higher unadjusted risk of mortality (hazard ratio 1.38, 95 % CI 1.25-1.52 and 1.20, 95 % CI 1.05-1.37). However, differences in mortality were no longer significant after adjusting for receipt of surgery.

CONCLUSIONS

Disparities in esophageal cancer outcomes are associated with the lower use of cancer-directed surgery. To decrease disparities in mortality it will be necessary to understand and target underlying causes of lower surgery rates in nonwhite patients and develop interventions, especially for midesophageal cancers.

Racial disparities in surgical resection and survival among elderly patients with poor prognosis cancer

BACKGROUND

Reports indicate that black patients have lower survival after the diagnosis of a poor prognosis cancer, compared with white patients. We explored the extent to which this disparity is attributable to the underuse of surgery.

STUDY DESIGN

Using the Surveillance, Epidemiology, and End Results program and Medicare database, we identified 57,364 patients, ages 65 years and older, with a new diagnosis of nonmetastatic liver, lung, pancreatic, and esophageal cancer, from 2000 to 2005. We evaluated racial differences in resection rates after adjustment for patient, tumor, and hospital characteristics using hierarchical logistic regression. Cox proportional hazards regression was used to assess racial differences in survival after adjusting for patient, tumor, and hospital characteristics, and receipt of surgery.

RESULTS

Compared with white patients, black patients were less likely to undergo surgery for liver (adjusted odds ratio [aOR] = 0.49; 95% CI, 0.29-0.83), lung (aOR = 0.62; 95% CI, 0.56-0.69), pancreas (aOR = 0.53; 95% CI, 0.41-0.70), and esophagus cancers (aOR = 0.64; 95% CI, 0.42-0.99). Hospitals varied in their surgery rates among patients with potentially resectable disease. However, resection rates were consistently lower for black patients, regardless of the resection rate of the treating hospital. Although there were no racial differences in overall survival with liver and esophageal cancer, black patients experienced poorer survival for lung (adjusted hazard ratio = 1.05; 95% CI, 1.00-1.10) and pancreas cancer (adjusted hazard ratio = 1.15; 95% CI, 1.03-1.30). In both instances, there were no residual racial disparities in overall survival after adjusting for use of surgery.

CONCLUSIONS

Black patients are less likely to undergo surgery after diagnosis of a poor prognosis cancer. Our findings suggest that surgery is an important predictor of overall mortality, and that efforts to reduce racial disparities will require stakeholders to gain a better understanding of why elderly black patients are less likely to get to the operating room.

Vitamin D receptor expression and neoadjuvant therapy in esophageal adenocarcinoma

Esophageal adenocarcinoma carries a poor prognosis. Tumor response to neoadjuvant therapy is a key prognostic factor in patients with adenocarcinoma of the esophagus, but is inconsistent. Identifying tumor characteristics that portend a favorable response to neoadjuvant therapy would be a valuable clinical tool. The anticancer actions of vitamin D and its receptor may have implications. In this study, 15 biopsy specimens were procured retrospectively from patients being treated for adenocarcinoma of the esophagus. The tissue was immunostained for the vitamin D receptor and compared on the basis of response to neoadjuvant therapy. Tumors that did not respond to neoadjuvant therapy had greater expression of VDR than tumors that responded completely. Expression of VDR declined with tumor de-differentiation. The data suggest that a relationship between vitamin D receptor expression and response to neoadjuvant therapy is plausible.