1
|
Lavergne C, Youssef A, Niglas M, Humphreys DN, Youssef Y. Outcomes from a single institution cohort of 248 patients with stage I-III esophageal cancer treated with radiotherapy: Comparison of younger and older populations. Tech Innov Patient Support Radiat Oncol 2024; 31:100260. [PMID: 39070540 PMCID: PMC11278076 DOI: 10.1016/j.tipsro.2024.100260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/07/2024] [Accepted: 06/28/2024] [Indexed: 07/30/2024] Open
Abstract
Outcomes for patients receiving radiotherapy (RT) for non-metastatic esophageal cancer at a single institution were assessed, as well as the impact of factors including age and intensity modulated RT (IMRT) planning on patient outcomes. A retrospective cohort of patients treated with RT for stage I-III esophageal cancer between 2010 and 2018 was identified. Among 248 identified patients, 28 % identified as older (≥75 years of age). Other than histology, there were no other statistically significant differences in patient and tumour characteristics between the younger and older populations. Treatments varied between the two age groups, with significantly less older patients completing trimodality treatments (17 % vs 58 %). Median overall survival (M-OS) and progression-free survival (M-PFS) were 20 months and 12 months for all patients and 40 months and 26 months for trimodality patients, respectively. In the older patients, the M-OS improved from 13 months for all to 34 months for trimodality patients; and M-PFS from 10 months to 16 months. On multivariate analysis, the use of trimodality therapy showed improved OS (HR 0.26, p < 0.001). In the non-surgical older patient group, significantly better survival was seen in patients who had a heart V30Gy under 46 %. There was no significant difference in M-OS in patients planned with IMRT compared with 3D-conformal RT. Clinical outcomes in the treatment of esophageal cancer vary significantly by treatment approach, with the most favourable results in those receiving trimodality therapy. Among older patients deemed fit after assessment by the multidisciplinary team for trimodality treatments, the M-OS is comparable to the younger patient group.
Collapse
Affiliation(s)
- Carrie Lavergne
- R.S. McLaughlin Durham Regional Cancer Centre, Lakeridge Health Oshawa, Oshawa, Ontario L1G 2B9, Canada
| | - Andrew Youssef
- Institute of Medical Science, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Mark Niglas
- R.S. McLaughlin Durham Regional Cancer Centre, Lakeridge Health Oshawa, Oshawa, Ontario L1G 2B9, Canada
- Queen’s University, Department of Oncology, Kingston, Ontario, Canada
| | - Deanna Ng Humphreys
- R.S. McLaughlin Durham Regional Cancer Centre, Lakeridge Health Oshawa, Oshawa, Ontario L1G 2B9, Canada
| | - Youssef Youssef
- R.S. McLaughlin Durham Regional Cancer Centre, Lakeridge Health Oshawa, Oshawa, Ontario L1G 2B9, Canada
| |
Collapse
|
2
|
Schiller S, Carmeli I, Orgad R, Kashtan H, Cooper L, Solomon D. Esophagectomy in the Older Adult: A Systematic Review. J Laparoendosc Adv Surg Tech A 2024; 34:464-478. [PMID: 38587375 DOI: 10.1089/lap.2024.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024] Open
Abstract
Current management of esophageal carcinoma (EC) involves combining different modalities, offering the opportunity of personalized strategies. This is particularly enticing in the geriatric population, where tailoring treatment modalities remains key to achieve good outcomes in terms of both quality of life and survival. Primary outcomes of our review included (1) evidence on short-term outcomes following esophagectomy, and (2) evidence on long-term outcomes following esophagectomy. Secondary review questions compared outcomes of (1) neoadjuvant treatment versus upfront surgery for locally advanced esophageal carcinoma, (2) endoscopic submucosal dissection versus esophagectomy for early esophageal carcinoma, and (3) definitive radiation with or without chemotherapy versus surgery. Twenty-six articles were included in the review for the main review questions. Our systematic review underscores the need for comprehensive geriatric evaluations to guide decision-making. Despite concerns about perioperative risks, well-selected older patients can derive survival benefits from surgical intervention.
Collapse
Affiliation(s)
| | - Idan Carmeli
- Division of General Surgery, Samson Assuta Ashdod Hospital, Ashdod, Israel
- Faculty of Medicine, Ben Gurion University of the Negev, Beersheba, Israel
| | - Ran Orgad
- Division of General Surgery, Samson Assuta Ashdod Hospital, Ashdod, Israel
| | - Hanoch Kashtan
- Division of General Surgery, Samson Assuta Ashdod Hospital, Ashdod, Israel
- Faculty of Medicine, Ben Gurion University of the Negev, Beersheba, Israel
| | - Lisa Cooper
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Geriatrics, Rabin Medical Center, Petach Tikva, Israel
| | - Daniel Solomon
- Division of General Surgery, Samson Assuta Ashdod Hospital, Ashdod, Israel
| |
Collapse
|
3
|
Schroeder J, Lagisetty K, Lynch W, Lin J, Chang AC, Reddy RM. Rural Women Have a Prolonged Recovery Process after Esophagectomy. Cancers (Basel) 2024; 16:1078. [PMID: 38539414 PMCID: PMC10968561 DOI: 10.3390/cancers16061078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 02/26/2024] [Accepted: 03/01/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Gender and geographic access to care play a large role in health disparities in esophageal cancer care. The aim of our study was to evaluate disparities in peri-operative outcomes for patients undergoing esophagectomy based on gender and geographic location. METHODS A retrospective cohort of prospectively collected data from patients who underwent esophagectomy from 2003 to 2022 was identified and analyzed based on gender and county, which were aggregated into existing state-level "metropolitan" versus "rural" designations. The demographics, pre-operative treatment, surgical complications, post-operative outcomes, and length of stay (LOS) of each group were analyzed using chi-squared, paired t-tests and single-factor ANOVA. RESULTS Of the 1545 patients, men (83.6%) and women (16.4%) experienced similar rates of post-operative complications, but women experienced significantly longer hospital (p = 0.002) and ICU (p = 0.03) LOSs as compared with their male counterparts, with no differences in 30-day mortality. When separated by geographic criteria, rural women were further outliers, with significantly longer hospital LOSs (p < 0.001) and higher rates of ICU admission (p < 0.001). CONCLUSIONS Rural female patients undergoing esophagectomy were more likely to have a longer inpatient recovery process compared with their female metropolitan or male counterparts, suggesting a need for more targeted interventions in this population.
Collapse
Affiliation(s)
- Julia Schroeder
- University of Michigan Medical School, 3808 Medical Science Bldg, Ann Arbor, MI 48109, USA
| | - Kiran Lagisetty
- University of Michigan Medical School, 3808 Medical Science Bldg, Ann Arbor, MI 48109, USA
- Michigan Medicine, Section of Thoracic Surgery, Department of Surgery, 1500 E. Medical Center Drive, TC 2120, Ann Arbor, MI 48109, USA
| | - William Lynch
- University of Michigan Medical School, 3808 Medical Science Bldg, Ann Arbor, MI 48109, USA
- Michigan Medicine, Section of Thoracic Surgery, Department of Surgery, 1500 E. Medical Center Drive, TC 2120, Ann Arbor, MI 48109, USA
| | - Jules Lin
- University of Michigan Medical School, 3808 Medical Science Bldg, Ann Arbor, MI 48109, USA
- Michigan Medicine, Section of Thoracic Surgery, Department of Surgery, 1500 E. Medical Center Drive, TC 2120, Ann Arbor, MI 48109, USA
| | - Andrew C. Chang
- University of Michigan Medical School, 3808 Medical Science Bldg, Ann Arbor, MI 48109, USA
- Michigan Medicine, Section of Thoracic Surgery, Department of Surgery, 1500 E. Medical Center Drive, TC 2120, Ann Arbor, MI 48109, USA
| | - Rishindra M. Reddy
- University of Michigan Medical School, 3808 Medical Science Bldg, Ann Arbor, MI 48109, USA
- Michigan Medicine, Section of Thoracic Surgery, Department of Surgery, 1500 E. Medical Center Drive, TC 2120, Ann Arbor, MI 48109, USA
| |
Collapse
|
4
|
Ahmed N, Tankel J, Asselah J, Alcindor T, Alfieri J, David M, Najmeh S, Spicer J, Cools-Lartigue J, Mueller C, Ferri L. Survival and perioperative outcomes of octo- and nonagenarians with resectable esophageal carcinoma. Dis Esophagus 2023; 36:doad043. [PMID: 37448141 DOI: 10.1093/dote/doad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Indexed: 07/15/2023]
Abstract
The outcomes of different treatment modalities for patients aged 80 and above with locally advanced and resectable esophageal carcinoma are not well described. The aim of this study was to explore survival and perioperative outcomes among this specific group of patients. A retrospective, cohort analysis was performed on a prospectively maintained esophageal cancer database from the McGill regional upper gastroinestinal cancer network. Between 2010 and 2020, all patients ≥80 years with cT2-4a, Nany, M0 esophageal carcinoma were identified and stratified according to the treatment modality: Neoadjuvant chemotherapy (nCT) or chemoradiotherapy (nCRT); definitive CRT (dCRT); upfront surgery; palliative CT/RT; or best supportive care (BSC). Of the 162 patients identified, 79 were included in this study. The median age was 83 years (80-97), most were cT3 (73%), cN- (56%), and had adenocarcinoma (62%). Treatment included: nCT/nCRT (16/79, 20%); surgery alone (19/79, 24%); dCRT (12/29, 15%); palliative RT/CT (27/79, 34%); and BSC (5/79, 6%). Neoadjuvant treatment was completed in 10/16 (63%). Of the 35/79 who underwent surgery, major complications occurred in 13/35 (37%) and 90-day mortality in 3/35 (9%). Overall survival (OS) for the cohort at 1- and 3-years was 58% and 19%. Among patients treated with nCT/nCRT, this was 94% and 46% respectively. Curative intent treatment (nCT/nCRT/upfront surgery/dCRT) had significantly increased 1- and 3- year OS compared with non-curative treatment (76%/31% vs. 34%/3.3%). Multimodal standard of care treatment is feasible and safe in select octo/nonagenarians, and may be associated with improved OS. Age alone should not bias against treatment with curative intent.
Collapse
Affiliation(s)
- Nabeel Ahmed
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jamil Asselah
- Division of Medical Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Thierry Alcindor
- Division of Medical Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joanne Alfieri
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marc David
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sara Najmeh
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jonathan Cools-Lartigue
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Carmen Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Lorenzo Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| |
Collapse
|
5
|
Huang Y, Huang X, Wang A, Chen Q, Chen G, Ye J, Wang Y, Qin Z, Xu K. Individualized treatment decision model for inoperable elderly esophageal squamous cell carcinoma based on multi-modal data fusion. BMC Med Inform Decis Mak 2023; 23:237. [PMID: 37872517 PMCID: PMC10594800 DOI: 10.1186/s12911-023-02339-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/15/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND This research aimed to develop a model for individualized treatment decision-making in inoperable elderly patients with esophageal squamous cell carcinoma (ESCC) using machine learning methods and multi-modal data. METHODS A total of 189 inoperable elderly ESCC patients aged 65 or older who underwent concurrent chemoradiotherapy (CCRT) or radiotherapy (RT) were included. Multi-task learning models were created using machine learning techniques to analyze multi-modal data, including pre-treatment CT images, clinical information, and blood test results. Nomograms were constructed to predict the objective response rate (ORR) and progression-free survival (PFS) for different treatment strategies. Optimal treatment plans were recommended based on the nomograms. Patients were stratified into high-risk and low-risk groups using the nomograms, and survival analysis was performed using Kaplan-Meier curves. RESULTS The identified risk factors influencing ORR were histologic grade (HG), T stage and three radiomic features including original shape elongation, first-order skewness and original shape flatness, while risk factors influencing PFS included BMI, HG and three radiomic features including high gray-level run emphasis, first-order minimum and first-order skewness. These risk factors were incorporated into the nomograms as independent predictive factors. PFS was substantially different between the low-risk group (total score ≤ 110) and the high-risk group (total score > 110) according to Kaplan-Meier curves (P < 0.05). CONCLUSIONS The developed predictive models for ORR and PFS in inoperable elderly ESCC patients provide valuable insights for predicting treatment efficacy and prognosis. The nomograms enable personalized treatment decision-making and can guide optimal treatment plans for inoperable elderly ESCC patients.
Collapse
Affiliation(s)
- Yong Huang
- Department of Medical Oncology, The Second People's Hospital of Hefei, Hefei, China
| | - Xiaoyu Huang
- Department of Chinese Integrative Medicine Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Anling Wang
- Scholl of Internet, Anhui University, Hefei, China
| | - Qiwei Chen
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Gong Chen
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jingya Ye
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yaru Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhihui Qin
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Kai Xu
- Scholl of Internet, Anhui University, Hefei, China.
| |
Collapse
|
6
|
Roeder F, Jensen AD, Lindel K, Mattke M, Wolf F, Gerum S. Geriatric Radiation Oncology: What We Know and What Can We Do Better? Clin Interv Aging 2023; 18:689-711. [PMID: 37168037 PMCID: PMC10166100 DOI: 10.2147/cia.s365495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/22/2023] [Indexed: 05/13/2023] Open
Abstract
Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.
Collapse
Affiliation(s)
- Falk Roeder
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
- Correspondence: Falk Roeder, Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Müllner Hauptstrasse 48, Salzburg, 5020, Austria, Tel +43 57255 55569, Email
| | - Alexandra D Jensen
- Department of Radiation Oncology, University Hospital Marburg-Giessen, Giessen, Germany
| | - Katja Lindel
- Department of Radiation Oncology, Städtisches Klinikum, Karlsruhe, Germany
| | - Matthias Mattke
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Frank Wolf
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Sabine Gerum
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| |
Collapse
|
7
|
The Role of Age and Comorbidities in Esophagogastric Cancer Chemoradiation of the Frail Elderly (>70 Years): An Analysis from a Tertiary High Volume-Center. Cancers (Basel) 2022; 15:cancers15010106. [PMID: 36612103 PMCID: PMC9817865 DOI: 10.3390/cancers15010106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/12/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
Elderly patients > 70 years of age with esophageal cancer (EC) represent a challenging group as frailty and comorbidities need to be considered. The aim of this retrospective study was to evaluate the efficacy and side effects of curative chemoradiation therapy (CRT) with regard to basic geriatric screening in elderly patients in order to elucidate prognostic factors. Thirty-four elderly patients > 70 years with EC treated at our cancer center between May 2014 and October 2018 fulfilled the selection criteria for this retrospective analysis. Treatment consisted of intravenous infusion of carboplatin/paclitaxel or fluorouracil (5-FU)/cisplatin with the intention of neoadjuvant or definite chemoradiation. Clinicopathological data including performance status (ECOG), (age-adjusted) Charlson comorbidity index (CCI), Frailty-scale by Fried, Mini Nutritional Assessment Short Form, body mass index, C-reactive protein to albumin ratio, and treatment-related toxicity (CTCAE) were assessed. Data were analyzed as predictors of overall survival (OS) and progression-free survival (PFS). All patients (ten female, 24 male) received combined CRT (22 patients in neoadjuvant, 12 patients in definite intent). Median age was 75 years and the ECOG index between 0 and 1 (52.9% vs. 35.3%); four patients were rated as ECOG 3 (11.8%). Median follow-up was 24 months. Tumors were mainly located in the lower esophagus or esophagogastric-junction with an T3 stage (n = 25; 75.8%) and N1 stage (n = 28; 90.3%). 15 patients (44.1%) had SCC, 19 patients (55.9%) AC. 26 of the patients (76.5%) were scored as prefrail and 50% were in risk for malnutrition (n = 17). In relation to the BMI, ten patients (29.4%) were ranked as overweight, and 15 patients were presented in a healthy state of weight (44.1%). Grade 3 acute toxicity (or higher) occured in nine cases (26.5%). Most of the patients did not show any late toxicities (66.7%). Trimodal therapy provides a significant prolonged OS (p = 0.049) regardless of age, but without impact on PFS. Our analysis suggests that chemoradiation therapy is feasible for elderly patients (>70 years) with tolerable toxicity. Trimodal therapy of EC shows a positive effect on OS and PFS. Further studies are needed to elucidate benefitting subgroups within the elderly. In addition to age, treatment decisions should be based on performance status, nutritional condition and multidisciplinary validated geriatric screening tools.
Collapse
|
8
|
Kamarajah SK, Evans RPT, Griffiths EA, Gossage JA, Pucher PH. Definitive chemoradiotherapy versus neoadjuvant chemoradiotherapy followed by radical surgery for locally advanced oesophageal squamous cell carcinoma: meta-analysis. BJS Open 2022; 6:6880880. [PMID: 36477836 PMCID: PMC9728519 DOI: 10.1093/bjsopen/zrac125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/27/2022] [Accepted: 09/05/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The literature lacks robust evidence comparing definitive chemoradiotherapy (dCRT) with neoadjuvant chemoradiotherapy and surgery (nCRS) for oesophageal squamous cell carcinoma (ESCC). This study aimed to compare long-term survival of these approaches in patients with ESCC. METHODS A systematic review performed according to PRISMA guidelines included studies identified from PubMed, Scopus, and Cochrane CENTRAL databases up to July 2021 comparing outcomes between dCRT and nCRS for ESCC. The main outcome measure was overall survival (OS), secondary outcome was disease-free survival (DFS). A meta-analysis was conducted using random-effects modelling to determine pooled adjusted multivariable hazard ratios (HRs). RESULTS Ten studies including 14 092 patients were included, of which 30 per cent received nCRS. Three studies were randomized clinical trials (RCTs) and the remainder were retrospective cohort studies. dCRT and nCRS regimens were reported in six studies and surgical quality control was reported in two studies. Outcomes for OS and DFS were reported in eight and three studies respectively. Following meta-analysis, nCRS demonstrated significantly longer OS (HR 0.68, 95 per cent c.i. 0.54 to 0.87, P < 0.001) and DFS (HR 0.50, 95 per cent c.i. 0.36 to 0.70, P < 0.001) compared with dCRT. CONCLUSION Neoadjuvant chemoradiotherapy followed by oesophagectomy correlated with improved survival compared with definitive chemoradiation in the treatment of ESCC; however, there is a lack of literature on RCTs.
Collapse
Affiliation(s)
- Sivesh K Kamarajah
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Richard P T Evans
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Philip H Pucher
- Correspondence to: Philip Pucher, Department of Surgery, Portsmouth University Hospitals NHS Trust, Cosham, Portsmouth, PO2 1LY, UK (e-mail: )
| |
Collapse
|
9
|
Linde P, Mallmann M, Adams A, Wegen S, Rosenbrock J, Trommer M, Marnitz S, Baues C, Celik E. Chemoradiation for elderly patients (≥ 65 years) with esophageal cancer: a retrospective single-center analysis. Radiat Oncol 2022; 17:187. [PMCID: PMC9670495 DOI: 10.1186/s13014-022-02160-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
Background Present studies on the efficacy and safety of curative chemoradiation therapy (CRT) with esophageal cancer reflect heterogenous results especially in elderly patients. The aim of this study was to evaluate the toxicity and efficacy of CRT in patients ≥ 65 years. In a cohort, the focus centered around treatment-related toxicity (CTCAE Grade > 3), overall survival as well as progression free survival, comparing these rates in-between patients older than 70 years to those younger than 70 years.
Methods A total of 67 patients older than 65 years (34 (50.7%) were older than 70 years) met the inclusion criteria for retrospective analysis (period from January 2013 to October 2017). Treatment consisted of radiotherapy and chemotherapy with carboplatin/paclitaxel or fluorouracil (5-FU)/cisplatin with the intention of neoadjuvant or definite chemoradiation. A sum of 67 patients received CRT (44 (65.6%) patients in neoadjuvant, 23 (34.4%) in definite intent). Of these, 22 and 12 patients were older than 70 years (50% and 52.2% in both treatment groups, respectively). Median age was 71 years and patients had a good physical performance status (ECOG 0: 57.6%, ECOG 1: 27.3%). Median follow-up was 24 months. Most patients had advanced tumour stages (T3 stage: n = 51, 79.7%) and nodal metastasis (N1 stage: n = 54, 88.5%). A subgroup comparison was conducted between patients aged ≤ 70 years and > 70 years. Results In severe (CTCAE Grade 3–5) toxicities (acute and late), no significant differences were observed between both patient groups (< 70 years vs. > 70 years). 21% had acute grade 3 events, 4 patients (4%) had grade 4 events, and two patients (3%) had one grade 5 event. Late toxicity after CRT was grade 1 in 13 patients (22%), grade 2 in two (3%), grade 3 in two (3%), grade 4 in four (7%), and grade 5 in one (2%). Median overall survival (OS) of all patients was 30 months and median progression-free survival (PFS) was 16 months. No significant differences were seen for OS (32 months vs. 25 months; p = 0.632) and PFS (16 months vs. 12 months; p = 0.696) between older patients treated with curative intent and younger ones. Trimodal therapy significantly prolonged both OS and PFS (p = 0.005; p = 0.018), regardless of age.
Conclusion CRT in elderly patients (≥ 65 years) with esophageal cancer is feasible and effective. Numbers for acute and late toxicities can be compared to cohorts of younger patients (< 65 years) with EC who received the same therapies. Age at treatment initiation alone should not be the determining factor. Instead, functional status, risk of treatment-related morbidities, life expectancy and patient´s preferences should factor into the choice of therapy.
Collapse
Affiliation(s)
- Philipp Linde
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Markus Mallmann
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Anne Adams
- grid.6190.e0000 0000 8580 3777Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Simone Wegen
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Johannes Rosenbrock
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Maike Trommer
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Simone Marnitz
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Christian Baues
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Eren Celik
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| |
Collapse
|
10
|
Gaber CE, Shaheen NJ, Sandler RS, Edwards JK, Nichols HB, Sanoff HK, Lund JL. Patterns of care amongst older adults diagnosed with locally advanced esophageal cancer: A cohort study. J Geriatr Oncol 2022; 13:1178-1187. [PMID: 36008272 DOI: 10.1016/j.jgo.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/24/2022] [Accepted: 08/15/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Since the early 2010s, neoadjuvant chemoradiation followed by esophagectomy (trimodal therapy) has been a recommended treatment for patients diagnosed with locally advanced esophageal cancer. However, it may also add treatment-related toxicity, particularly for older adults with significant comorbidity and frailty burdens. We examined contemporary patterns of care in older adults, which have not been well characterized. MATERIALS AND METHODS We used the Surveillance Epidemiology and End Results-Medicare database to identify a cohort of US adults aged 66 years and older diagnosed with incident locally advanced esophageal cancer between 2004 and 2017. Calendar year age-standardized percentages of treatment receipt were calculated. Joinpoint regression was used to detect temporal trends in treatment receipt. Descriptive associations between patient factors and treatment were assessed. Trend analyses quantified how the percentage of trimodal and definitive chemoradiation (no surgery) patients receiving cisplatin-based, carboplatin-based, and other chemotherapy regimens evolved over time. RESULTS In total, 4332 adults aged ≥66 years with locally advanced esophageal cancer were included. The age-standardized percentage of patients receiving trimodal therapy increased from 16.7% in 2004 to 26.1% in 2017 (annual percent change = 3.5%; 95% confidence interval [CI], 0.7%-6.4%) in adenocarcinomas and from 7.3% in 2004 to 9.1% in 2017 (annual percent change = 0.4%; 95% CI, -4.1%-5.1%) in squamous cell carcinomas. By 2017, definitive chemoradiation became the most frequently used treatment modality for adenocarcinomas (49.8%; 95% CI, 43.5-56.0) and squamous cell carcinomas (59.5%; 95% CI, 50.8-68.2). Patients with higher comorbidity and frailty burdens were less likely to be treated with trimodal therapy. Amongst patients receiving chemoradiation as part of their treatment, a large and swift channeling away from cisplatin and towards carboplatin-based regimens was observed. DISCUSSION In practice, definitive chemoradiation is the most commonly received treatment by older adults with locally advanced esophageal cancer. Four out of five older adults do not receive trimodal therapy, some of whom are potentially undertreated.
Collapse
Affiliation(s)
- Charles E Gaber
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435, USA.
| | - Nicholas J Shaheen
- University of North Carolina at Chapel Hill, School of Medicine, Department of Medicine, 21 S Columbia St, Chapel Hill, NC 27516, USA
| | - Robert S Sandler
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435, USA; University of North Carolina at Chapel Hill, School of Medicine, Department of Medicine, 21 S Columbia St, Chapel Hill, NC 27516, USA
| | - Jessie K Edwards
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435, USA
| | - Hazel B Nichols
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435, USA
| | - Hanna K Sanoff
- University of North Carolina at Chapel Hill, School of Medicine, Department of Medicine, 21 S Columbia St, Chapel Hill, NC 27516, USA
| | - Jennifer L Lund
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435, USA
| |
Collapse
|
11
|
Yang Y, Chen M, Xie J, Ji Y, Sheng L, Qiu G, Du X, Wei Q. Treatment Patterns and Outcomes of Elderly Patients With Potentially Curable Esophageal Cancer. Front Oncol 2022; 12:778898. [PMID: 35237508 PMCID: PMC8882918 DOI: 10.3389/fonc.2022.778898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 01/24/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives The proportion of elderly patients with esophageal cancer (EC) is increasing due to prolonged life expectancy and aging process. The aim of the study is to explore the optimal treatment strategy for elderly patients (aged ≥70 years) with locally advanced EC. Methods Eligible patients with cT2-4aNxM0 EC were identified in the Surveillance, Epidemiology, and End Results database from 2010 to 2016. Treatment patterns were divided into six groups: surgical resection (S), chemoradiotherapy (CRT), trimodality therapy (CRT+S), radiotherapy (RT), chemotherapy (CT), or observation with no treatment (Obs). Survival between groups was compared using the log-rank test, and the Cox proportional hazards model was used to identify factors associated with overall survival (OS). Results A total of 2917 patients with potentially curable EC were identified. Of all the patients included, 6.7%, 51.8%, 18.0%, 9.4% and 3.6%received S, CRT, CRT+S, RT, and CT, respectively, whereas 10.6% underwent Obs. The 3-year OS estimates were 30.2% (95% confidence interval [CI]: 23.5–38.9%), 25.4% (95% CI: 22.8–28.3%),44.3% (95% CI: 39.3–49.9%), 11.4% (95% CI: 7.7–17.0%), 16.1% (95% CI: 9.1–28.3%), and 5.6% (95% CI: 3.2–9.8%) for S, CRT, CRT+S RT, CT, and Obs (p<0.001), respectively. Overall, patents underwent CRT+S had the longest OS, compared to other treatment patterns, and the survival difference was not significant between patients receiving CRT and S (p=0.12) in the elderly population. However, the survival benefits of trimodality therapy over CRT gradually weakened with the increase in age, and became statistically non-significant for EC patients aged ≥80 years (p=0.35). Multivariate analysis showed that treatment patterns, age, sex, tumor grade, T stage, N stage, and marital status were significantly associated with OS. Conclusion Generally, the use of trimodality therapy was associated with the longest OS, the survival benefits were comparable between CRT and S alone, and CRT was superior to RT or CT alone in elderly patients with curable EC. For patients intolerable to surgery or aged ≥80 years, definitive CRT should be considered as a preferable option.
Collapse
Affiliation(s)
- Yang Yang
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Thoracic Radiotherapy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Zhejiang Key Laboratory of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Mengyuan Chen
- Department of Thoracic Radiotherapy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Zhejiang Key Laboratory of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Jiping Xie
- Department of Radiation Oncology, Yuyao People’s Hospital, Ningbo, China
| | - Yongling Ji
- Department of Thoracic Radiotherapy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Zhejiang Key Laboratory of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Liming Sheng
- Department of Thoracic Radiotherapy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Zhejiang Key Laboratory of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Guoqin Qiu
- Department of Thoracic Radiotherapy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Zhejiang Key Laboratory of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Xianghui Du
- Department of Thoracic Radiotherapy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Zhejiang Key Laboratory of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Qichun Wei
- Department of Radiation Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Qichun Wei,
| |
Collapse
|
12
|
Chang JW, Jung DH, Huh CW, Park JC, Shin SK, Lee SK, Lee YC. Long-Term Outcomes and Prognostic Factors of Superficial Esophageal Cancer in Patients Aged ≥ 65 Years. Front Med (Lausanne) 2022; 8:722141. [PMID: 35118082 PMCID: PMC8804291 DOI: 10.3389/fmed.2021.722141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 12/27/2021] [Indexed: 12/14/2022] Open
Abstract
BackgroundThe number of elderly patients with superficial esophageal cancer (SEC) is increasing. We aimed to evaluate the clinical outcomes and prognostic factors of overall survival (OS) in elderly patients undergoing endoscopic submucosal dissection (ESD) or surgical resection for SEC.MethodsBetween January 2001 and May 2020, 290 patients aged ≥65 years who underwent ESD or surgical resection for SEC were evaluated. Their clinical outcomes and prognosis were assessed, and independent risk factors for OS were identified.ResultsThe mean patient age (269 men and 21 women) was 70.9 years (range 65–90 years). En bloc, R0, and curative resections were achieved in 94.5%, 90.0%, and 73.4% of the patients, respectively. During the follow-up [mean: 54.6 months (range: 1–210 months)], 79 patients died. The 3-, 5-, and 10-year OS rates were 82.5, 73.1, and 59.7%, respectively. In multivariate analysis, cancer history of the other organs, American Society of Anesthesiologists performance status, and presence of lymphovascular involvement (hazard ratio = 1.852, 1.656, and 1.943, respectively; all P < 0.05) were independent risk factors for poor OS. The high-risk group (≥2 risk factors) showed a significantly lower OS than the low-risk group (≤ 1 risk factor) (P < 0.001).ConclusionsThe three risk factors could be useful in predicting the long-term prognosis of elderly patients with SEC.
Collapse
Affiliation(s)
- Jin Won Chang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- *Correspondence: Da Hyun Jung
| | - Cheal Wung Huh
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- Cheal Wung Huh
| | - Jun Chul Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Kwan Shin
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang Kil Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| |
Collapse
|
13
|
Zheng C, Luo C, Xie K, Qiang Y, Wang GM, Shen Y. Distinguishing optimal esophagectomy candidates in elderly patients: A nomogram based on propensity score matching. Eur J Surg Oncol 2021; 48:909-916. [PMID: 34952748 DOI: 10.1016/j.ejso.2021.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/19/2021] [Accepted: 12/12/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND A survival benefit from esophagectomy was observed in elderly patients. But it's unclear how to identify specific patients who can benefit. Thus, we aimed to establish a predictive model to identify optimal candidates for esophagectomy. METHODS Patients (age ≥75 years) with esophageal cancer in Surveillance, Epidemiology and End Results (SEER) database were used to establish the predictive model. Propensity-score matching (PSM) was applied to eliminate the imbalance between esophagectomy group and non-esophagectomy group. We hypothesized that elderly patients could benefit from esophagectomy with longer cancer specific survival (CSS) time than those who did not receive esophagectomy. Patients received surgery were divided into beneficial group and non-beneficial group according to the median CSS time of non-esophagectomy group. Prognostic factors affecting patients' long-term survival were identified. Among esophagectomy group, a logistic regression model based on these factors was established to build a nomogram. RESULTS A total of 7,025 eligible patients were extracted from the SEER database, with 831 patients received esophagectomy. Surgery was independently associated with better long-term survival (median CSS time in the matched population: 35 vs. 8 months, p < 0.001). As a result, 361 (68.6%) patients were divided into beneficial group (CSS >8 months). Factors including age, tumor site, histology, differentiation grade, TNM stage, and tumor size were used to formulate the nomogram, which was named as esophagectomy candidates screening score (ECSS). The validation from two aspects showed the model a useful and stable one. CONCLUSION A predictive model was established to distinguish optimal candidates for esophagectomy among elderly patients with EC.
Collapse
Affiliation(s)
- Chao Zheng
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Chao Luo
- Department of Cardiothoracic Surgery, Jinling Hospital, Southern Medical University, Guangzhou, China
| | - Kai Xie
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Gao-Ming Wang
- Department of Thoracic Surgery, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Xuzhou, China.
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China; Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China.
| |
Collapse
|
14
|
Lv H, Chao C, Wang B, Wang Z, Qian Y, Zhang X. The effect of surgery plus chemoradiotherapy on survival of elderly patients with stage Ⅱ-Ⅲ esophageal cancer: a SEER-based demographic analysis. Cancer Med 2021; 10:8483-8496. [PMID: 34800005 PMCID: PMC8633220 DOI: 10.1002/cam4.4352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/28/2021] [Accepted: 09/24/2021] [Indexed: 12/14/2022] Open
Abstract
Background The optimal treatment for elderly patients with esophageal cancer (EC) remains controversial. In the present study, we aimed to investigate whether elderly patients with stage II–III EC could benefit from trimodal therapy. Methods The selected elderly patients with stage II–III EC between 2004 and 2015 were included in a retrospective cohort study from the Surveillance, Epidemiology, and End Results database. The patients were divided into two groups based on whether or not they underwent surgery. The inverse probability of treatment weighting (IPTW) analysis was used to balance the confounding factors between the two groups. The Cox regression analysis, the log‐rank test, and the Kaplan–Meier curves were conducted to identify the survival benefits of different treatment regimes. Results A total of 1596 patients were included in this cohort study, in which 278 patients underwent surgery. In the combination of chemoradiotherapy and surgery group, there were more male patients, more patients aged between 75 and 79 years, and more married patients in the surgery group. Moreover, there were more patients with adenomatous carcinoma, more patients with a tumor size of less than 5 cm, and more patients with a T3 stage in the combination group. In the survival analysis, patients in the combination group had a longer overall survival (OS) and EC‐specific survival (ECSS). After IPTW analysis, the survival analysis generated similar results. The competitive risk model found that our results were stable. There was still a significant difference in OS and ECSS between the combination group and chemoradiotherapy alone group for esophageal adenocarcinoma (p < 0.001). Conclusions Elderly patients with stage II–III EC, especially those with adenocarcinoma, could benefit from the combination of surgery and chemoradiotherapy.
Collapse
Affiliation(s)
- Hao Lv
- Department of Cardiothoracic Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Ce Chao
- Department of Cardiothoracic Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Bin Wang
- Department of Cardiothoracic Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Zhigang Wang
- Department of Cardiothoracic Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yongxiang Qian
- Department of Cardiothoracic Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiaoying Zhang
- Department of Cardiothoracic Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| |
Collapse
|
15
|
Del Calvo H, Nguyen DT, Chan EY, Chihara R, Graviss EA, Kim MP. Surgery provides improved overall survival in surgically fit octogenarians with esophageal cancer after chemoradiation therapy. J Thorac Dis 2021; 13:5875-5886. [PMID: 34795936 PMCID: PMC8575846 DOI: 10.21037/jtd-21-928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/19/2021] [Indexed: 11/29/2022]
Abstract
Background Multiple randomized controlled trials have shown that multimodal therapy provides the best overall survival for patients who had locally advanced esophageal cancer. However, it is unknown if multimodal therapy offers the best overall survival in octogenarians. Methods We performed retrospective cohort study using data obtained from the National Cancer Database (NCDB) for octogenarians who had locally advanced esophageal cancer from 2004 to 2015. We evaluated the 5-year overall survival for patients among different therapies. We compared the 5-year overall survival between patients receiving chemoradiation therapy followed by surgery and a propensity-matched group of patients who underwent chemoradiation only. Results There were 21,710 octogenarians (15%) with esophageal cancer in the NCDB database. Among octogenarians, there were 6,960 patients (32%) who had clinical stage II–III esophageal cancer. Among 6,922 patients whose treatment data were available, the most common therapy was chemoradiation (n=3,360, 49%). Two of the most common therapies that included surgical resection were surgery only (n=314, 5%) and chemoradiation therapy followed by surgery (n=172, 2%). Among different treatments, the best 5-year overall survival was achieved in patients receiving chemoradiation therapy followed by surgery (P<0.001). In the propensity score-matched cohort between chemoradiation therapy followed by surgery (n=83) to chemoradiation therapy only (n=83), there was an association with improved 5-year overall survival in the patients who had chemoradiation therapy followed by surgery (17.9%) compared to the patients who underwent chemoradiation only (5.7%, P=0.003). Conclusions Most octogenarians with locally advanced esophageal cancer underwent definitive chemoradiation therapy. Very few patients underwent chemoradiation followed by surgery; however, the multimodality treatment provided increased overall survival. Surgically fit octogenarians should be considered for chemoradiation therapy followed by surgery.
Collapse
Affiliation(s)
- Haydee Del Calvo
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Edward Y Chan
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Ray Chihara
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Min P Kim
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| |
Collapse
|
16
|
Li X, Zhang J, Ye C, Zhu J, Guo K, Guo Y. Impact of chemotherapy and radiotherapy on the survival of elderly esophageal cancer patients undergoing surgery: a SEER database analysis. BMC Gastroenterol 2021; 21:430. [PMID: 34794384 PMCID: PMC8603580 DOI: 10.1186/s12876-021-02016-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 11/08/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Esophageal cancer (EC) is a common and lethal carcinoma; however, the effectiveness and feasibility of the chemo- and radio-therapy (CRT) for the elderly patients (≥ 70 years) with surgery have not been fully discussed. The purpose of this study was to investigate the potential effect of CRT on the prognosis. METHODS A total of 1085 patients (534 CRT patients vs. 551 non-CRT patients) from 1998 to 2016 were collected from the Surveillance, Epidemiology, and End Results database according to the inclusion and exclusion criteria. Using the competing risk regression and survival analysis, an overall estimation of the effectiveness of CRT was performed on a well-balanced cohort via performing propensity score matching. Then, the specific impact of CRT on high- (n = 557) and low-risk (n = 528) cohorts derived from the nomogram's risk quantification for every patient were further evaluated respectively. Additionally, the advantages of the nomogram model and the conventional tumor, node, metastasis (TNM, 6th revision) staging system were compared. RESULTS A better survival outcome was observed among patients receiving both surgery and CRT than those who underwent surgery alone (HR: 0.55, 95% CI 0.45-0.68, P < 0.001), especially for those with tumors characterized by poor differentiation, large tumor size, advanced T staging, lymphatic metastasis, and distant metastasis (HR: 0.48, 95% CI 0.39-0.59, P < 0.001), while no benefit was observed among the low-risk patients. Furthermore, the newly established nomogram model might be better than the TNM (6th revision) staging system but more data needed. CONCLUSION Aggressive treatments, such as surgery, chemotherapy, and radiotherapy, were considered effective for selected elderly patients with EC according to the newly established nomogram model.
Collapse
Affiliation(s)
- Xinrong Li
- Department of Integrative Medicine and Medical Oncology, Shengzhou People's Hospital (the First Affiliated Hospital of Zhejiang University Shengzhou Branch), Shengzhou, 312400, Zhejiang, People's Republic of China
| | - Jin Zhang
- The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, People's Republic of China
| | - Chenxiao Ye
- The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, People's Republic of China
| | - Junquan Zhu
- Department of Integrative Medicine and Medical Oncology, Shengzhou People's Hospital (the First Affiliated Hospital of Zhejiang University Shengzhou Branch), Shengzhou, 312400, Zhejiang, People's Republic of China
| | - Kaibo Guo
- The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, People's Republic of China
| | - Yong Guo
- Department of Medical Oncology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310006, Zhejiang, People's Republic of China.
| |
Collapse
|
17
|
Cooper L, Dezube AR, De León LE, Kucukak S, Mazzola E, Dumontier C, Mamon H, Enzinger P, Jaklitsch MT, Frain LN, Wee JO. Outcomes of trimodality CROSS regimen in older adults with locally advanced esophageal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:2667-2674. [PMID: 33895020 PMCID: PMC8448942 DOI: 10.1016/j.ejso.2021.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/29/2021] [Accepted: 04/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chemoradiotherapy for Esophageal cancer followed by Surgery (CROSS regimen) is standard of care for locally-advanced esophageal cancer. We evaluated CROSS completion rates, toxicity, and postoperative outcomes between older and younger adults receiving trimodality therapy. METHODS Retrospective analysis of patients with locally-advanced esophageal cancer who underwent CROSS regimen from May 2016 to January 2020 at a single academic center. Outcomes of those aged ≥70-years-old and <70 years-old were analyzed. RESULTS Of 201 patients, 136 were <70 and 65 were ≥70 years. Older adults were more likely to be male (91% vs. 79%; p = 0.045), have higher ECOG scores (median 1 vs. 0; p = 0.003), Charlson-comorbidity index (median 6 vs. 4; p < 0.001), and undergo open procedures (20% vs. 8% p = 0.008). Most completed CROSS regimen (78% vs. 84% respectively) with similar rates of treatment discontinuation and dose reduction (all p > 0.05). Time to surgery following neoadjuvant therapy was similar between age groups, except in those ≥80-years-old as compared to <70-years-old (p < 0.05). Overall toxicity rates were similar (68% vs. 71% respectively; p = 0.676). Only rates of delirium (19% vs. 5%) and urinary retention (9% vs. 0%) were higher in older adults (both p < 0.05). Length of stay, discharge disposition, mortality, and overall survival were similar. Age was not an independent risk factor for complication, neoadjuvant toxicity or completion, surgery timing, nor worse overall or recurrence-free survival (p > 0.05). CONCLUSION Trimodality CROSS regimen for esophageal cancer in older adults is feasible, with similar completion rates and postoperative outcomes as compared to their younger counterparts.
Collapse
Affiliation(s)
- Lisa Cooper
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA.
| | - Aaron R Dezube
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Luis E De León
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Emanuele Mazzola
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA, USA
| | - Clark Dumontier
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA; Marcus Institute of Aging Research, Boston, MA, USA
| | - Harvey Mamon
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter Enzinger
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | | | - Laura N Frain
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA
| | - Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
18
|
Delman AM, Ammann AM, Turner KM, Vaysburg DM, Van Haren RM. A narrative review of socioeconomic disparities in the treatment of esophageal cancer. J Thorac Dis 2021; 13:3801-3808. [PMID: 34277070 PMCID: PMC8264668 DOI: 10.21037/jtd-20-3095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/31/2020] [Indexed: 12/11/2022]
Abstract
The persistent challenges of disparities in healthcare have led to significantly distinct outcomes among patients from different racial, ethnic, and underserved populations. Esophageal Cancer, not unlike other surgical diseases, has seen significant disparities in care. Esophageal cancer is currently the 6th leading cause of death from cancer and the 8th most common cancer in the world. Surgical disparities in the care of patients with Esophageal Cancer have been described in the literature, with a prevailing theme associating minority status with worse outcomes. The goal of this review is to provide an updated account of the literature on disparities in Esophageal Cancer presentation and treatment. We will approach this task through a conceptual framework that highlights the five main themes of surgical disparities: patient-level factors, provider-level factors, system and access issues, clinical care and quality, and postoperative outcomes, care and rehabilitation. All five categories play a complex role in the delivery of high-quality, equitable care for patients with Esophageal Cancer. While describing disparities in care is the first step to correcting them, moving forward, we should focus on developing effective interventions to mitigate disparities, policies linking disparities to quality-of-care metrics, and delivery system change to enable minority patients to more easily access high volume centers.
Collapse
Affiliation(s)
- Aaron M Delman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Allison M Ammann
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kevin M Turner
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dennis M Vaysburg
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert M Van Haren
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
19
|
Conway P, Leach M, Tejani N, Robinson A, Shethia Y, Solo I. Oesophageal cancer treatment patterns, timeliness of care and outcomes in the Loddon Mallee region of Victoria: A retrospective cohort study. J Med Imaging Radiat Oncol 2021; 65:242-250. [PMID: 33634598 DOI: 10.1111/1754-9485.13167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/16/2020] [Accepted: 02/03/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Few studies have investigated oesophageal cancer care in regional areas. This study aimed to describe treatment patterns for oesophageal cancer in a regional area, and to identify factors associated with radiotherapy utilisation, timeliness of care, and death. METHODS In a retrospective cohort study, medical records were reviewed to source data on all patients diagnosed with and/or treated for oesophageal cancer at two regional Victorian hospitals over July 2015-June 2018. Cox proportional hazards regression was employed to identify factors associated with time from diagnosis to death while binary logistic regression was used to identify factors associated with radiotherapy utilisation and treatment within 28 days of diagnosis - a time frame derived from the relevant optimal care pathway. RESULTS Of 95 patients, 72% had radiotherapy, 32% received any treatment within 28 days, and 78% died over a median time of nine months. Odds of not receiving radiotherapy were decreased (odds ratio [OR] = 0.26, 95% confidence interval [CI] = 0.08-0.87) for histology other than adenocarcinoma. Odds of timely care were increased for any palliative radiotherapy (OR = 3.47, 95% CI = 1.15-10.5) and decreased for older age (OR = 0.95, 95% CI = 0.91.0.999). Hazard of death was elevated for stage IV disease (hazard ratio [HR] = 2.73, 95% CI = 1.64-4.54) and reduced for radical intent (HR = 0.27, 95% CI = 0.15-0.48). CONCLUSION Nearly three-quarters of regional oesophageal cancer patients had radiotherapy while approximately one-third received any treatment within the recommended 28 days. Any palliative radiotherapy and younger age were associated with timely treatment. Future studies could further investigate factors related to timely oesophageal cancer care.
Collapse
Affiliation(s)
- Paul Conway
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Michael Leach
- Loddon Mallee Integrated Cancer Service, Bendigo, Victoria, Australia.,School of Rural Health, Monash University, Bendigo, Victoria, Australia
| | - Neetu Tejani
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Amanda Robinson
- Loddon Mallee Integrated Cancer Service, Bendigo, Victoria, Australia
| | - Yachna Shethia
- Loddon Mallee Integrated Cancer Service, Bendigo, Victoria, Australia
| | - Ilana Solo
- Loddon Mallee Integrated Cancer Service, Bendigo, Victoria, Australia
| |
Collapse
|
20
|
Raja S, Sudarshan M. Commentary: First Do No Harm But Also Don't Forget to Treat! Semin Thorac Cardiovasc Surg 2021; 33:895-896. [PMID: 33600985 DOI: 10.1053/j.semtcvs.2020.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/10/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Monisha Sudarshan
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
21
|
Madhavan A, Kamarajah SK, Navidi M, Wahed S, Immanuel A, Hayes N, Griffin SM, Phillips AW. The impact of age on patients undergoing transthoracic esophagectomy for cancer. Dis Esophagus 2021; 34:5859088. [PMID: 32556151 DOI: 10.1093/dote/doaa056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/18/2020] [Accepted: 05/23/2020] [Indexed: 12/11/2022]
Abstract
To compare long-term and short-term outcomes in patients <70 years old with those ≥ 70 years old, who underwent transthoracic esophagectomy for carcinoma. With an ageing population more patients, with increasing co-morbidities are being diagnosed with potentially curable esophageal cancer. Concerns exist regarding offering older patients esophagectomy, conversely undue prejudice may exists that may prevent surgery being offered. Consecutive patients from a single unit between January 2000 and July 2016 that underwent trans-thoracic esophagectomy with or without neoadjuvant treatment for carcinoma were included. Short-term outcomes including morbidity, mortality, length of stay and long-term survival were compared between those <70 and those ≥ 70. This study identified 992 patients who underwent esophagectomy during the study period, of which 302 (30%) ≥ 70 years old. Greater proportion ≥ 70 years old had SCC (squamous cell carcinoma) (23%) than <70 (18%) (p = 0.07). Patients ≥ 70 years old were noted to have higher ASA Grade 3 (34% vs 25%, p = 0.004) and were less likely to receive neoadjuvant treatment (64% vs 45% p<0.001). Length of stay was longer in ≥ 70 (14 vs 17 days p<0.001), and there were more complications (63% vs 75% p<0.001). In hospital mortality was higher in ≥ 70 (2% vs 5% p = 0.026). Overall survival was 50 months in <70 vs 36 months in ≥ 70 (p = <0.001). In <70s with adenocarcinoma, overall survival was 52 months vs 35 months in the ≥ 70 (p<0.001). No significant difference in survival in patients with SCC, 49 months in <70 vs 54 months in ≥ 70 (p = 0.711). Increased peri-operative morbidity and mortality combined with the reduction in the long term survival in the over 70s cohort should be addressed when counselling patients undergoing curative resection for oesophageal cancer.
Collapse
Affiliation(s)
- Anantha Madhavan
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Sivesh K Kamarajah
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Maziar Navidi
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S Wahed
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Arul Immanuel
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Nick Hayes
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S Michael Griffin
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | |
Collapse
|
22
|
Motoyama S, Maeda E, Iijima K, Sato Y, Koizumi S, Wakita A, Nagaki Y, Fujita H, Yoneya T, Imai K, Terata K, Minamiya Y, Higashi T. Does Esophagectomy Provide a Survival Advantage to Patients Aged 80 Years or Older? Analyzing 5,066 Patients in the National Database of Hospital-Based Cancer Registries in Japan. Ann Surg 2020; 276:e16-e23. [DOI: 10.1097/sla.0000000000004437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
23
|
Rhodin KE, Raman V, Jawitz OK, Voigt SL, Farrow NE, Harpole DH, Tong BC, D'Amico TA. Patterns of Use of Induction Therapy for T2N0 Esophageal Cancer. Ann Thorac Surg 2020; 111:440-447. [PMID: 32681837 DOI: 10.1016/j.athoracsur.2020.05.089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/21/2020] [Accepted: 05/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Induction therapy for patients with cT2N0M0 esophageal cancer is controversial. We performed a retrospective cohort analysis of the National Cancer Database to examine the patterns of use of induction therapy for this population. METHODS The National Cancer Database was queried for patients with cT2N0M0 esophageal cancer who underwent esophagectomy (2004-2015). Patients were stratified by upfront surgery or induction therapy. Overall survival was analyzed and a multivariable logistic regression performed to identify factors associated with receipt of induction therapy. RESULTS Overall 2540 patients met study criteria: 1177 (46%) received upfront esophagectomy and 1363 (53%) received induction therapy. Patients receiving induction therapy were more likely to be younger, male, without comorbidities, privately insured, and treated at a nonacademic center. These patients were also less likely to be treated in highest volume surgery centers. In multivariable regression, factors independently associated with receipt of induction therapy included later year of diagnosis, increasing tumor size, and increasing tumor grade. Factors associated with upfront esophagectomy included advancing age, comorbidities, lack of insurance, geographic location, and highest volume centers. The receipt of induction chemotherapy was not associated with a survival benefit compared with no induction therapy. CONCLUSIONS Several patient-, treatment center-, and tumor-related factors are associated with receipt of induction therapy for cT2N0M0 esophageal cancer, although induction therapy is not associated with a survival benefit. Further inquiry into these differences and the potential benefit or lack thereof of induction therapy should be conducted to provide more equitable and appropriate care for patients with esophageal cancer.
Collapse
Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Vignesh Raman
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Oliver K Jawitz
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Soraya L Voigt
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Norma E Farrow
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - David H Harpole
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Betty C Tong
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thomas A D'Amico
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
24
|
Raman V, Jawitz OK, Voigt SL, Rhodin KE, Kim AW, Tong BC, D'Amico TA, Harpole DH. Patterns of Care in Neoadjuvant Chemoradiotherapy for Node-Positive Esophageal Adenocarcinoma. Ann Thorac Surg 2020; 110:1832-1839. [PMID: 32622794 DOI: 10.1016/j.athoracsur.2020.05.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 05/02/2020] [Accepted: 05/08/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aims of this study were to examine the factors associated with use of neoadjuvant chemoradiotherapy (NCR) for patients with locally advanced esophageal cancer and to evaluate the effect of NCR on survival. METHODS The 2004 to 2015 National Cancer Database was used to identify patients with cT1-4aN1-3M0 (stage II-IVA) esophageal adenocarcinoma who underwent esophagectomy. Patients were stratified by receipt of NCR. A multivariable logistic regression was performed to examine factors associated with NCR, and survival between the 2 groups was compared using a multivariable Cox model. RESULTS Of 8076 patients meeting the study criteria, 1616 (20%) did not receive NCR and 6460 (80%) did. In a multivariable regression, factors associated with receipt of NCR were a later year of diagnosis, treatment in a high-volume center, and clinical stage III disease. Factors associated with nonreceipt of NCR were increasing age, comorbidities, and treatment in a Middle Atlantic, South Central, or Pacific state. Receipt of trimodality therapy was associated with improved survival compared with other or no perioperative therapies (adjusted hazard ratio, 0.80; 95% confidence interval, 0.74-0.87). CONCLUSIONS Numerous personal-, demographic-, and treatment center-related factors account for variability in NCR for clinically node-positive esophageal adenocarcinoma, although neoadjuvant therapy was associated with a survival benefit. Further efforts are needed to identify reasons for these differences and design interventions to provide more equitable care for patients with esophageal cancer.
Collapse
Affiliation(s)
- Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Soraya L Voigt
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Kristen E Rhodin
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Anthony W Kim
- Division of Thoracic Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Betty C Tong
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thomas A D'Amico
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - David H Harpole
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
25
|
Definitive Chemoradiotherapy Compared to Neoadjuvant Chemoradiotherapy With Esophagectomy for Locoregional Esophageal Cancer. Ann Surg 2020; 275:526-533. [DOI: 10.1097/sla.0000000000003941] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
26
|
Bakhos CT, Salami AC, Kaiser LR, Petrov RV, Abbas AE. Outcomes of octogenarians with esophageal cancer: an analysis of the National Cancer Database. Dis Esophagus 2019; 32:1-8. [PMID: 30596899 DOI: 10.1093/dote/doy128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 10/26/2018] [Indexed: 12/11/2022]
Abstract
The optimal treatment of esophageal cancer in octogenarians is controversial. While the safety of esophagectomy has been demonstrated in elderly patients, surgery and multimodality therapy are still offered to a select group. Additionally, the long-term outcomes in octogenarians have not been thoroughly compared to those in younger patients. We sought to compare the outcomes of esophageal cancer treatment between octogenarians and non-octogenarians in the National Cancer Database (2004-2014). The major endpoints were early postoperative mortality and long-term survival. A total of 107,921 patients were identified [octogenarian-16,388 (15.2%)]. Compared to non-octogenarians, octogenarians were more likely to be female, of higher socioeconomic status, and had more Charlson comorbidities (p < 0.001 for all). Octogenarians were significantly less likely to undergo esophagectomy (11.5% vs. 33.3%; p < 0.001) and multimodality therapy (2.0% vs. 18.5%; p < 0.001), a trend that persisted following stratification by tumor stage and Charlson comorbidities. Both 30-day and 90-day mortality were higher in the octogenarian group, even after multivariable adjustment (p ≤ 0.001 for both). Octogenarians who underwent multimodality therapy had worse long-term survival when compared to younger patients, except for those with stage III tumors and no comorbidities (HR: 1.29; p = 0.153). Within the octogenarian group, postoperative mortality was lower in academic centers, and the long-term survival was similar between multimodality treatment and surgery alone (HR: 0.96; p = 0.62). In conclusion, octogenarians are less likely to be offered treatment irrespective of tumor stage or comorbidities. Although octogenarians have higher early mortality and poorer overall survival compared to younger patients, outcomes may be improved when treatment is performed at academic centers. Multimodality treatment did not seem to confer a survival advantage compared to surgery alone in octogenarians, and more prospective studies are necessary to better elucidate the optimal treatment in this patient population.
Collapse
Affiliation(s)
- C T Bakhos
- Department of Thoracic Medicine and Surgery, Temple University Hospital.,Department of Surgery, Albert Einstein Healthcare Network, Philadelphia, USA
| | - A C Salami
- Department of Surgery, Albert Einstein Healthcare Network, Philadelphia, USA
| | - L R Kaiser
- Department of Thoracic Medicine and Surgery, Temple University Hospital
| | - R V Petrov
- Department of Thoracic Medicine and Surgery, Temple University Hospital
| | - A E Abbas
- Department of Thoracic Medicine and Surgery, Temple University Hospital
| |
Collapse
|
27
|
Martin P, O'Leary E, Deady S, Horgan A. The Uptake and Efficacy of Neoadjuvant Therapy in Older Adults with Locally Advanced Esophogastric Cancer. J Gastrointest Cancer 2019; 51:893-900. [PMID: 31701400 DOI: 10.1007/s12029-019-00320-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Data on Neo+/- adjuvant treatment in older patients with cancer is sparse. The management of locally advanced esophagogastric cancer (LAEC) in older patients was evaluated to determine treatment modalities and identify factors associated with survival. METHODS Patients diagnosed with LAEC (stage II or III) over 5 years were identified from the National Cancer Registry of Ireland. Treatment was classified as "best supportive care (BSC)," "surgery only," "neo/adjuvant treatment," and "chemo/radiation alone."Survival was assessed. Univariate and multivariate analysis (MVA) of clinicopathological factors and treatment was conducted. RESULTS Forty-six percent (n = 580) of the 1251 patients were ≥ 70 years, 11% (n = 134) received BSC, 23% (n = 288) surgery only, 31% (n = 390) had chemo/radiation alone, and 35% (n = 439) had neo/adjuvant treatment. Forty-six percent, 10%, and 0% of patients < 75, ≥ 75, and ≥ 80 years of age, respectively, received neoadjuvant treatment. Age was associated with treatment received (p < 0.001). Older patients were less likely to receive neo/adjuvant treatment, surgery, and any treatment. Median survival (OS) decreased with age (< 70 years: 23 months; 70-74: 19 months; 75-79: 13 months; ≥ 80 years: 10 months). In MVA, older age, smoking, later stage, and higher grade were significantly associated with a higher risk of death. Patients receiving neo/adjuvant treatment had lower risk of death than any other treatment group regardless of age. CONCLUSION Older patients were less likely to receive treatment for LAEC than younger patients. Patients aged ≥ 70 years benefit from neo/adjuvant treatment. Prospective clinical trials focusing on older patients and incorporating life expectancy, comorbidities, and geriatric assessment are needed to guide treatment.
Collapse
Affiliation(s)
- Petra Martin
- University Hospital Waterford, Waterford, Ireland. .,Midland Regional Hospital Tullamore, Tullamore, Ireland. .,St. James's Hospital, Dublin, Ireland.
| | | | - Sandra Deady
- National Cancer Registry Ireland (NCRI), Cork, Ireland
| | - Anne Horgan
- University Hospital Waterford, Waterford, Ireland
| |
Collapse
|
28
|
Schlottmann F, Gaber C, Strassle PD, Herbella FAM, Molena D, Patti MG. Disparities in esophageal cancer: less treatment, less surgical resection, and poorer survival in disadvantaged patients. Dis Esophagus 2019; 33:5487976. [PMID: 31076759 PMCID: PMC8205620 DOI: 10.1093/dote/doz045] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 04/02/2019] [Accepted: 04/09/2019] [Indexed: 12/11/2022]
Abstract
The incidence of esophageal cancer has increased steadily in the last decades in the United States. The aim of this paper was to characterize disparities in esophageal cancer treatment in different racial and socioeconomic population groups and compare long-term survival among different treatment modalities. A retrospective analysis of the National Cancer Database was performed including adult patients (≥18 years old) with a diagnosis of resectable (stages I-III) esophageal cancer between 2004 and 2015. Multivariable logistic regression models were used to determine the odds of being offered no treatment at all and surgical treatment across race, primary insurance, travel distance, income, and education levels. Multivariable Cox proportional hazards models were used to compare 5-year survival rates across different treatment modalities. A total of 60,621 esophageal cancer patients were included. Black patients, uninsured patients, and patients living in areas with lower levels of education were more likely to be offered no treatment. Similarly, black race, female patients, nonprivately insured patients, and those living in areas with lower median residential income and lower education levels were associated with lower rates of surgery. Patients receiving surgical treatment, compared to both no treatment and definitive chemoradiation, had significant better long-term survival in stage I, II, and III esophageal cancer. In conclusion, underserved patients with esophageal cancer appear to have limited access to surgical care, and are, in fact, more likely to not be offered any treatment at all. Considering the survival benefits associated with surgical resection, greater public health efforts to reduce disparities in esophageal cancer are needed.
Collapse
Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA,Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina,Address correspondence to: Francisco Schlottmann, MD MPH, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7081, Chapel Hill, NC 27599-7081, USA.
| | - Charles Gaber
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA,Department of Epidemiology, Gillings School of Global Public Health
| | - Paula D Strassle
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA,Department of Epidemiology, Gillings School of Global Public Health
| | | | - Daniela Molena
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marco G Patti
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA,Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
29
|
Nobel TB, Lavery JA, Barbetta A, Gennarelli RL, Lidor AO, Jones DR, Molena D. National guidelines may reduce socioeconomic disparities in treatment selection for esophageal cancer. Dis Esophagus 2019; 32:doy111. [PMID: 30496376 PMCID: PMC6514299 DOI: 10.1093/dote/doy111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The 2011 National Comprehensive Cancer Network guidelines first incorporated the results of the landmark CROSS trial, establishing induction therapy (chemotherapy ± radiation) and surgery as the treatment standard for locoregional esophageal cancer in the United States. The effect of guideline publication on socioeconomic status (SES) inequalities in cancer treatment selection remains unknown. Patients diagnosed with Stage II/III esophageal cancer between 2004 and 2013 who underwent curative treatment with definitive chemoradiation or multimodality treatment (induction and surgery) were identified from the Surveillance, Epidemiology and End Results (SEER)-Medicare registry. Clinicopathologic characteristics were compared between the two therapies. Multivariable regression analysis was used to adjust for known factors associated with treatment selection. An interaction term with respect to guideline publication and SES was included Of the 2,148 patients included, 1,478 (68.8%) received definitive chemoradiation and 670 (31.2%) induction and surgery. Guideline publication was associated with a 16.1% increase in patients receiving induction and surgery in the low SES group (21.4% preguideline publication vs. 37.5% after). In comparison, a 4.5% increase occurred during the same period in the high SES status group (31.8% vs. 36.3%). After adjusting for factors associated with treatment selection, guideline publication was associated with a 78% increase in likelihood of receiving induction and surgery among lower SES patients (odds ratio 1.78; 95% confidence interval (CI): 1.05,3.03). Following the new guideline publication, patients living in low SES areas were more likely to receive optimal treatment. Increased dissemination of guidelines may lead to increased adherence to evidence-based treatment standards.
Collapse
Affiliation(s)
- T B Nobel
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Environmental Medicine and Public Health, Mount Sinai Hospital, New York, New York
| | - J A Lavery
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - A Barbetta
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - R L Gennarelli
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - A O Lidor
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - D R Jones
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - D Molena
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
30
|
Nobel TB, Curry M, Gennarelli R, Jones DR, Molena D. Higher clinical suspicion is needed for prompt diagnosis of esophageal adenocarcinoma in young patients. J Thorac Cardiovasc Surg 2019; 159:317-326.e5. [PMID: 31126651 PMCID: PMC6801049 DOI: 10.1016/j.jtcvs.2019.03.095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/13/2019] [Accepted: 03/31/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Esophageal cancer is considered a disease of the elderly. Although the incidence of esophageal adenocarcinoma in young patients is increasing, current guidelines for endoscopic evaluation of gastroesophageal reflux disease and Barrett's esophagus include age as a cutoff. There is a paucity of data on the presentation and treatment of esophageal cancer in young patients. Most studies are limited by small sample sizes, and conflicting findings are reported regarding delayed diagnosis and survival compared with older patients. METHODS A retrospective cohort study was performed using the National Cancer Database between 2004 and 2015. Patients with esophageal adenocarcinoma were divided into quartiles by age (18-57, 58-65, 66-74, 75+ years) for comparison. Clinicopathologic and treatment factors were compared between groups. RESULTS A total of 101,596 patients were identified with esophageal cancer. The youngest patient group (18-57 years) had the highest rate of metastatic disease (34%). No difference in tumor differentiation was observed between age groups. Younger patient groups were more likely to undergo treatment despite advanced stage at diagnosis. Overall 5-year survival was better for younger patients with local disease, but the difference was less pronounced in locoregional and metastatic cases. CONCLUSIONS In this study, young patients were more likely to have metastatic disease at diagnosis. Advanced stage in young patients may reflect the need for more aggressive clinical evaluation in high-risk young patients.
Collapse
Affiliation(s)
- Tamar B Nobel
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Environmental Medicine and Public Health, Mount Sinai Hospital, New York, NY
| | - Michael Curry
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Renee Gennarelli
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David R Jones
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniela Molena
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
| |
Collapse
|
31
|
Schlottmann F, Strassle PD, Molena D, Patti MG. Influence of Patients' Age in the Utilization of Esophagectomy for Esophageal Adenocarcinoma. J Laparoendosc Adv Surg Tech A 2019; 29:213-217. [PMID: 30362867 PMCID: PMC6909734 DOI: 10.1089/lap.2018.0434] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The indication of surgical resection in esophageal cancer is often conditioned by patient's age. We aimed to assess the trends in utilization of surgical treatment for esophageal adenocarcinoma (EAC) in the United States, stratified by age groups. METHODS We performed a retrospective analysis of the National Cancer Institute's Surveillance, Epidemiology, and End Results program registry for the period 2004-2014. Adult patients (aged ≥18 years) diagnosed with EAC were eligible for inclusion. The yearly incidence of esophagectomy, stratified by age groups (18-49, 50-70, and >70 years old), was calculated using Poisson regression. Weighted log-binomial regression was used to compare the proportion of patients undergoing esophagectomy, within each age group. Inverse probability of treatment weights were used to account for potential confounders. RESULTS A total of 21,301 patients were included. During the study period, the rate of esophagectomy decreased from 34.1% to 28.2% (P = .40) in patients between 18 and 49 years old, from 38.6% to 33.3% (P = .06) in patients between 50 and 70 years old, and from 21.4% to 16.9% (P = .04) in patients older than 70 years. After accounting for patient and cancer characteristics, patients older than 70 years were 50% less likely to undergo esophagectomy compared with both patients between 18 and 49 years old (risk ratio [RR] 0.51, 95% confidence interval [CI] 0.45-0.57, P < .0001) and patients between 50 and 70 years old (RR 0.53, 95% CI 0.50-0.56, P < .0001). CONCLUSION Surgical resection is scarcely used in patients older than 70 years in the United States. Further investigation of surgical outcomes in elderly patients is warranted to determine if surgical treatment is underutilized in a large proportion of EAC patients.
Collapse
Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Department of Surgery, Hospital Alemán of Buenos Aires, University of Buenos Aires, Buenos Aires, Argentina
| | - Paula D. Strassle
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Daniela Molena
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marco G. Patti
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
32
|
Nobel TB, Molena D. From standardization to personalized medicine: Moving beyond cookie-cutter treatment of esophageal cancer. J Thorac Cardiovasc Surg 2018; 156:1736-1738. [PMID: 30248805 DOI: 10.1016/j.jtcvs.2018.06.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 06/17/2018] [Accepted: 06/18/2018] [Indexed: 11/20/2022]
Affiliation(s)
- Tamar B Nobel
- Division of Thoracic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Surgery, Mount Sinai Hospital, New York, NY
| | - Daniela Molena
- Division of Thoracic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
| |
Collapse
|
33
|
Toxopeus E, van der Schaaf M, van Lanschot J, Lagergren J, Lagergren P, van der Gaast A, Wijnhoven B. Outcome of Patients Treated Within and Outside a Randomized Clinical Trial on Neoadjuvant Chemoradiotherapy Plus Surgery for Esophageal Cancer: Extrapolation of a Randomized Clinical Trial (CROSS). Ann Surg Oncol 2018; 25:2441-2448. [PMID: 29948420 PMCID: PMC6029046 DOI: 10.1245/s10434-018-6554-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Indexed: 12/11/2022]
Abstract
Background Randomized clinical trials (RCTs) can provide a high level of evidence for medical decision making, but it is unclear if the results apply to patients treated outside such trials. Objective The aim of this study was to retrospectively compare outcomes of patients with esophageal cancer treated within and outside an RCT.
Methods All patients receiving neoadjuvant chemoradiotherapy (nCRT) plus surgery for esophageal cancer between 2002 and 2008 (ChemoRadiotherapy for Esophageal cancer followed by Surgery Study [CROSS] cohort) who participated in multicenter, phase II–III trials were compared with patients who underwent the same treatment outside the trial between 2008 and 2013 (post-CROSS cohort). The differences between these cohorts were analyzed using t tests, while logistic regression models were used to evaluate adverse events. Overall and disease-free survival were calculated using the Kaplan–Meier method and Cox regression analyses. Results A total of 208 CROSS patients and 173 post-CROSS patients were included in this study. Patients from the post-CROSS cohort were older, had more co morbidities, and had poorer performance status. Clinical N stage, but not cT stage, was worse in the post-CROSS cohort. There were no statistically significant differences in adverse events (pulmonary, cardiac, or anastomotic complications) or survival between the comparison cohorts. Conclusion The outcomes of patients treated with nCRT plus esophagectomy for cancer have a high external consistency and can be extrapolated to the daily practice of physicians involved in the treatment and care of esophageal cancer patients. Electronic supplementary material The online version of this article (10.1245/s10434-018-6554-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Eelke Toxopeus
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands.
| | - Maartje van der Schaaf
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Jan van Lanschot
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands
| | - Jesper Lagergren
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Division of Cancer Studies, King's College London, London, UK
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Ate van der Gaast
- Department of Medical Oncology, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands
| | - Bas Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
34
|
Underutilization of Treatment for Regional Gastric Cancer Among the Elderly in the USA. J Gastrointest Surg 2018; 22:955-963. [PMID: 29404983 PMCID: PMC5983904 DOI: 10.1007/s11605-018-3691-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/09/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND In the USA, a quarter of elderly patients do not receive any treatment for regional gastric cancer, which results in poorer outcomes. We sought to identify factors associated with undertreatment of regional gastric cancer in this population, as well as to assess overall survival in the undertreated population. METHODS Elderly patients (aged ≥ 65 years) diagnosed with regional gastric cancer between 2001 and 2009 were identified from the Surveillance Epidemiology and End Results (SEER)-Medicare linked databases. Treatment was defined as receiving any medical or surgical therapy for gastric cancer. Logistic regression analysis was used to identify factors associated with failure to receive treatment. Overall survival was analyzed using the Kaplan-Meier method and Cox proportional hazard model. RESULTS Of 5972 patients with regional gastric cancer, 1586 (26.5%) received no treatment. Median age was 78 years; 56.1% of patients were men. On multivariable analysis, the factors strongly associated with lack of therapy were age ≥ 80 years, black race, lower education level, and diagnosis before 2007. As expected, patients who received therapy had better overall survival (log-rank test, p < 0.001). Specifically, median survival and 5-year survival were 16.5 months and 20.5% for treated patients, compared with 9.1 months and 19.0% for untreated patients. CONCLUSIONS Elderly patients with gastric cancer have better overall 5-year survival after receiving treatment for their cancer. Disparities in the use of treatment for curable cancers are associated with older age, black race, lower educational level, and diagnosis before 2007.
Collapse
|
35
|
Walter F, Böckle D, Schmidt-Hegemann NS, Köpple R, Gerum S, Boeck S, Angele M, Belka C, Roeder F. Clinical outcome of elderly patients (≥ 70 years) with esophageal cancer undergoing definitive or neoadjuvant radio(chemo)therapy: a retrospective single center analysis. Radiat Oncol 2018; 13:93. [PMID: 29769143 PMCID: PMC5956563 DOI: 10.1186/s13014-018-1044-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/02/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To analyse the outcome of elderly patients (≥70 years) with esophageal cancer treated with curative intent radio(chemo)therapy. METHODS Fifty five patients (median 75 years) receiving curative intent radio(chemo)therapy for esophageal cancer from 1999 to 2015 were retrospectively analyzed. Most patients showed locally advanced disease (T3/4:78%, N+:58%) with squamous cell histology (74%). Charlson comorbidity score was > 1 in 27%. 48 patients (87%) received definitive treatment while 7 patients were treated neoadjuvantly. RT was carried out as 3D-conformal treatment or IMRT. Concurrent chemotherapy was applied in 85%, mainly cisplatin/5-FU or mitomycin/5-FU. 18FDG-PET/CT staging was used in 65%. RESULTS Median follow-up was 11 months (1-68) and 21 months in survivors. 1- and 2-year rates of LRC, DC, FFTF and OS were 60%/45, 81%/72, 55%/41 and 46%/26% for the entire cohort. In univariate analysis, addition of surgery was associated with improved LRC and FFTF, nodal involvement with improved DC and lower T stage, lower Charlson score and use of PET-CT with improved OS. In multivariate analysis, lower T stage and lower Charlson score remained significant for OS. Patients treated after 2008 showed a significantly improved FFTF (1-year FFTF 64% vs 35%) and OS (1-year OS 66% vs 24%). Maximum (chemo)radiation related grade3+ toxicity was observed in 80% including 7 deaths (13%). Grade5 toxicity was significantly associated with Charlson score (CS > 1:33% vs CS ≤ 1:5%) and treatment period (24% before vs 3% after 2008). The patients treated after 2008 included significantly more SCCs, less T4 stages, had a higher percentage of PET-CT staging and were treated with smaller field lengths. Trends were also observed for lower Charlson scores and increased use of IMRT. CONCLUSION Curative intent (chemo)radiation of elderly patients with esophageal cancer may result in considerable toxicity and unfavorable outcome. However, a clear improvement over time was observed in our cohort, probably based on improved patient selection. In patients with less advanced stages and lower comorbidity similar results as in younger cohorts seem achievable with modern staging and treatment approaches. Age per se should not be a decisive factor, but careful attention should be paid regarding patient selection including a structured and tight follow-up strategy.
Collapse
Affiliation(s)
- Franziska Walter
- Department of Radiation Oncology, University Hospital LMU Munich, Marchioninistr 15, 81377, Munich, Germany.
| | - David Böckle
- Department of Radiation Oncology, University Hospital LMU Munich, Marchioninistr 15, 81377, Munich, Germany
| | | | - Rebecca Köpple
- Department of Radiation Oncology, University Hospital LMU Munich, Marchioninistr 15, 81377, Munich, Germany
| | - Sabine Gerum
- Department of Radiation Oncology, University Hospital LMU Munich, Marchioninistr 15, 81377, Munich, Germany
| | - Stefan Boeck
- Department of Internal Medicine III, University Hospital LMU Munich, Marchioninistr, 15, 81377, Munich, Germany
| | - Martin Angele
- Department of Surgery, University Hospital LMU Munich, Marchioninistr, 15, 81377, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital LMU Munich, Marchioninistr 15, 81377, Munich, Germany
| | - Falk Roeder
- Department of Radiation Oncology, University Hospital LMU Munich, Marchioninistr 15, 81377, Munich, Germany.,Department of Molecular Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| |
Collapse
|
36
|
Barbetta A, Hsu M, Tan KS, Stefanova D, Herman K, Adusumilli PS, Bains MS, Bott MJ, Isbell JM, Janjigian YY, Ku GY, Park BJ, Wu AJ, Jones DR, Molena D. Definitive chemoradiotherapy versus neoadjuvant chemoradiotherapy followed by surgery for stage II to III esophageal squamous cell carcinoma. J Thorac Cardiovasc Surg 2018; 155:2710-2721.e3. [PMID: 29548582 DOI: 10.1016/j.jtcvs.2018.01.086] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 01/04/2018] [Accepted: 01/31/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Definitive chemoradiotherapy (CRT) remains the most commonly used treatment for locally advanced esophageal squamous cell carcinoma (SCC), because of perceptions that esophagectomy offers an unclear survival advantage. We compare recurrence, overall survival (OS), and disease-free survival (DFS) in patients treated with definitive CRT or neoadjuvant CRT followed by surgery (trimodality). METHODS This was a retrospective cohort study of patients with stage II and III SCC of the middle and distal esophagus in patients who completed CRT. Treatment groups were matched (1:1) on covariates using a propensity score-matching approach. The effect of trimodality treatment, compared with definitive CRT, on OS, DFS, and site-specific recurrence was evaluated as a time-dependent variable and analyzed using Cox regression with a gamma frailty term for matched units. RESULTS We included 232 patients treated between 2000 and 2016: 124 (53%) with definitive CRT and 108 (47%) with trimodality. Trimodality was used less frequently over time (61% before 2009 and 29% after 2009; P < .0001). After matching, each group contained 56 patients. Median OS and DFS were 3.1 and 1.8 years for trimodality versus 2.3 and 1.0 years for CRT. Surgery was independently associated with improved OS (hazard ratio, 0.57; 95% confidence interval, 0.34-0.97; P = .039) and DFS (hazard ratio, 0.51; 95% confidence interval, 0.32-0.83; P = .007). CONCLUSIONS CRT followed by surgery might decrease local recurrence and increase DFS and OS in patients with esophageal SCC. Until better tools to select patients with pathological complete response are available, surgery should remain an integral component of the treatment of locally advanced esophageal SCC.
Collapse
Affiliation(s)
- Arianna Barbetta
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Meier Hsu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dessislava Stefanova
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Koby Herman
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Prasad S Adusumilli
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Manjit S Bains
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Matthew J Bott
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James M Isbell
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yelena Y Janjigian
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Geoffrey Y Ku
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bernard J Park
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
| |
Collapse
|
37
|
Moreno AC, Zhang N, Verma V, Giordano SH, Lin SH. Treatment disparities affect outcomes for patients with stage I esophageal cancer: a national cancer data base analysis. J Gastrointest Oncol 2018; 10:74-84. [PMID: 30788162 DOI: 10.21037/jgo.2018.10.04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background To examine patterns of care and outcomes for patients with stage I esophageal cancer (EC) in the United States. Methods We identified patients in the National Cancer Data Base diagnosed with stage I EC from 2004 to 2012 and grouped them by primary treatment: esophagectomy (Eso), local excision (LE), concurrent chemoradiation (CRT), or observation (Obs). Multinomial logistic regression was used to predict receipt of treatments. Overall survival (OS) was estimated by Kaplan-Meier methods adjusted for inverse probability of treatment weighting (IPTW) and Cox proportional hazard regressions. Results Of 5,480 patients, 2,312 (42%) underwent Eso, 1,250 (23%) LE, 758 (14%) CRT, and 1,160 (21%) Obs. LE use increased over time from 17% to 29% while Obs declined from 26% to 19%. Patients least likely to undergo surgery were older, had greater comorbidity, were uninsured, were treated at non-academic centers, and were Black. The rate of surgery for Black patients was half of that for White patients (33% vs. 67%). Postoperative mortality rates were higher after Eso vs. LE at 30 days (2.9% vs. 0.5%; P<0.001) and at 90 days (5.5% vs. 1.4%, P<0.001). Five-year OS was 59% with Eso, 63% LE, 29% CRT, and 31% Obs (P<0.001). On multivariate analysis, outcomes were best after LE [vs. Eso: hazard ratio (HR) =1.15, 95% CI: 1.01-1.30, P=0.037; CRT: HR =2.41, 95% CI: 2.09-2.78, P<0.001; Obs: HR =3.79, 95% CI: 3.33-4.32, P<0.001). Conclusions Disparities are evident in the care of patients with stage I EC throughout the United States. LE was associated with favorable outcomes compared to Eso, CRT, and Obs.
Collapse
Affiliation(s)
- Amy C Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ning Zhang
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Buffett Cancer Center, Omaha, NE, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
38
|
Guttmann DM, Mitra N, Metz JM, Plastaras J, Feng W, Swisher-McClure S. Neoadjuvant chemoradiation is associated with improved overall survival in older patients with esophageal cancer. J Geriatr Oncol 2017; 9:40-46. [PMID: 28887066 DOI: 10.1016/j.jgo.2017.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/12/2017] [Accepted: 08/16/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The aim of this study was to characterize outcomes associated with neoadjuvant chemoradiation prior to esophagectomy, compared to esophagectomy alone, in older patients with esophageal cancer. MATERIALS AND METHODS We conducted an observational cohort study in patients ≥70years with locally-advanced esophageal cancer undergoing esophagectomy ± neoadjuvant chemoradiation between 2006 and 2012 using the National Cancer Database. A Cox proportional hazards model with inverse probability of treatment weighting (IPTW) using the propensity score was developed to assess the association between trimodality therapy and overall survival. Perioperative complications and pathologic outcomes associated with trimodality therapy were identified with multivariable logistic regression. RESULTS 1364 patients were included; the mean age was 75 (range 70-90). 904 (66%) were treated with trimodality therapy and 460 (34%) were treated with esophagectomy alone. On IPTW Cox analysis, neoadjuvant chemoradiation was associated with improved overall survival (HR=0.76, 95%CI [0.70-0.82], p≤0.001). Further, trimodality therapy was associated with lower rates of margin-positive resection (5% vs. 18%; OR=0.26, 95%CI [0.18-0.37], p<0.001) and in 18% of trimodality patients, there was no detectable tumor at surgery. 90-day mortality rates were not statistically different (14% vs. 12%; OR=0.99, 95%CI [0.73-1.36], p=0.22). Neoadjuvant chemoradiation was associated with lower 30-day readmission rates (5% vs. 8%; OR=0.48, 95%CI [0.31-0.73], p=0.004) and shorter surgical hospital stay (median 10 vs. 12days, p<0.001) compared to esophagectomy alone. CONCLUSION In older patients with esophageal cancer, trimodality therapy, compared to esophagectomy alone, is associated with improved overall survival and favorable pathologic and perioperative outcomes. Further studies are needed to identify which older patients are most suitable for trimodality therapy.
Collapse
Affiliation(s)
- David M Guttmann
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, TRC 2 West, Philadelphia, PA 19104, United States.
| | - Nandita Mitra
- Department of Biostatistics and Epidemiology, University of Pennsylvania, 622 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States
| | - James M Metz
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, TRC 2 West, Philadelphia, PA 19104, United States
| | - John Plastaras
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, TRC 2 West, Philadelphia, PA 19104, United States
| | - Weiwei Feng
- Department of Biostatistics and Epidemiology, University of Pennsylvania, 622 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States
| | - Samuel Swisher-McClure
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, TRC 2 West, Philadelphia, PA 19104, United States
| |
Collapse
|
39
|
Tsukada Y, Higashi T, Shimada H, Kikuchi Y, Terahara A. The use of neoadjuvant therapy for resectable locally advanced thoracic esophageal squamous cell carcinoma in an analysis of 5016 patients from 305 designated cancer care hospitals in Japan. Int J Clin Oncol 2017; 23:81-91. [PMID: 28795280 DOI: 10.1007/s10147-017-1178-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/31/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Recent studies have shown the benefits of neoadjuvant therapy with chemotherapy or chemoradiotherapy for resectable locally advanced thoracic esophageal squamous cell carcinoma (ESCC). The aim of our study was to elucidate the use of neoadjuvant therapy for thoracic ESCC in Japan. METHODS Data on patients with stage IB-III thoracic ESCC were retrieved from the national database of hospital-based cancer registries combined with claims data between 2012 and 2013. These data were analyzed using a mixed-effect logistic regression analysis, with a focus on exploring patterns in the first-line treatment for ESCC, including proportion of patients who received neoadjuvant therapy, and investigating the hospital characteristics and patient factors associated with the use of neoadjuvant therapy. RESULTS Of the 5016 patients with stage IB-III thoracic ESCC at the 305 participating hospitals, 34.2% received neoadjuvant therapy (neoadjuvant chemotherapy, 29.5%; neoadjuvant chemoradiotherapy, 4.7%). The therapy was less likely to be administered to older patients (≤64 years, 48.8%; 65-70 years, 42.0%; 70-75 years, 33.9%; 75-80 years, 22.2%; 80-85 years, 3.8%; ≥85 years, 1.4%) and at hospitals with a low volume of patients (very high, 42.1%; high, 37.5%; low, 30.7%; and very low, 26.4%). This trend was confirmed by regression analysis. CONCLUSIONS Based on our results, in Japan, relatively few patients with resectable locally advanced thoracic ESCC receive neoadjuvant therapy, with older patients and patients at lower volume hospitals being less likely than other patients to receive the neoadjuvant therapy. We recommend that the process of treatment decision-making be assessed at both the patient and hospital levels so that patients can consider various treatment options, including neoadjuvant therapy with surgery in Japan.
Collapse
Affiliation(s)
- Yoichiro Tsukada
- Division of Health Services Research, Center for Cancer Control and Information Services, National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan. .,Department of Radiology, Toho University Omori Medical Center, Tokyo, Japan. .,Department of Clinical Oncology, Toho University Graduate School of Medicine, Tokyo, Japan.
| | - Takahiro Higashi
- Division of Health Services Research, Center for Cancer Control and Information Services, National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Hideaki Shimada
- Department of Surgery, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Yoshinori Kikuchi
- Division of Gastorenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Atsuro Terahara
- Department of Radiology, Toho University Omori Medical Center, Tokyo, Japan
| |
Collapse
|
40
|
Bollschweiler E, Plum P, Mönig SP, Hölscher AH. Current and future treatment options for esophageal cancer in the elderly. Expert Opin Pharmacother 2017; 18:1001-1010. [DOI: 10.1080/14656566.2017.1334764] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Elfriede Bollschweiler
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
| | - Patrick Plum
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
| | - Stefan P. Mönig
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
- Service de Chirurgie viscéral, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Arnulf H. Hölscher
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
- Department of Surgery, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
| |
Collapse
|