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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.
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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
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2
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Muslim Z, Stroever S, Poulikidis K, Connery CP, Nitzkorski JR, Bhora FY. Impact of facility type and volume in locally advanced esophageal cancer. Asian Cardiovasc Thorac Ann 2024; 32:19-26. [PMID: 37994000 DOI: 10.1177/02184923231215539] [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: 11/24/2023]
Abstract
BACKGROUND We hypothesized that academic facilities and high-volume facilities would be independently associated with improved survival and a greater propensity for performing surgery in locally advanced esophageal cancer. METHODS We identified patients diagnosed with stage IB-III esophageal cancer during 2004-2016 from the National Cancer Database. Facility type was categorized as academic or community, and facility volume was based on the number of times a facility's unique identification code appeared in the dataset. Each facility type was dichotomized into high- and low-volume subgroups using the cutoff of 20 esophageal cancers treated/year. We fitted multivariable regression models in order to assess differences in surgery selection and survival between facilities according to type and volume. RESULTS Compared to patients treated at high-volume community hospitals, those at high-volume academic facilities were more likely to undergo surgery (odds ratio: 1.865, p < 0.001) and were associated with lower odds of death (odds ratio: 0.784, p = 0.004). For both academic and community hospitals, patients at high-volume facilities were more likely to undergo surgery compared to those at low-volume facilities, p < 0.05. For patients treated at academic facilities, high-volume facilities were associated with lower odds of death (odds ratio: 0.858, p = 0.02) compared to low-volume facilities, while there was no significant difference in the odds of death between high- and low-volume community hospitals (odds ratio: 1.018, p = 0.87). CONCLUSIONS Both facility type and case volume impact surgery selection and survival in locally advanced esophageal cancer. Compared to community hospitals, academic facilities were more likely to perform surgery and were associated with improved survival.
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Affiliation(s)
- Zaid Muslim
- Division of Thoracic Surgery, Rudy L. Ruggles Biomedical Research Institute, Danbury, CT, USA
| | | | | | - Cliff P Connery
- Division of Thoracic Surgery, Nuvance Health, Poughkeepsie, NY, USA
| | | | - Faiz Y Bhora
- Division of Thoracic Surgery, Rudy L. Ruggles Biomedical Research Institute, Danbury, CT, USA
- Division of Thoracic Surgery, Nuvance Health, Danbury, CT, USA
- Division of Thoracic Surgery, Nuvance Health, Poughkeepsie, NY, USA
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3
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Edmondson J, Hunter J, Bakis G, O’Connor A, Wood S, Qureshi AP. Understanding Post-Esophagectomy Complications and Their Management: The Early Complications. J Clin Med 2023; 12:7622. [PMID: 38137691 PMCID: PMC10743498 DOI: 10.3390/jcm12247622] [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: 10/11/2023] [Revised: 11/24/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Esophagectomy is a technically complex operation performed for both benign and malignant esophageal disease. Medical and surgical advancements have led to improved outcomes in esophagectomy patients over the past several decades; however, surgeons must remain vigilant as complications happen often and can be severe. Post-esophagectomy complications can be grouped into early and late categories. The aim of this review is to discuss the early complications of esophagectomy along with their risk factors, work-up, and management strategies with special attention given to anastomotic leaks.
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Affiliation(s)
| | | | | | | | | | - Alia P. Qureshi
- Division of General Surgery, Oregon Health & Science University, Machall 3186, Portland, OR 97239, USA; (J.E.)
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Abstract
Esophageal cancer is a deadly cancer. Advances in multimodal treatment have improved esophageal cancer outcomes. Advancements have not benefited all races equally. Major disparities in esophageal cancer outcomes exist. Minorities undergo fewer surgical resections of esophageal cancer and have poorer outcomes.
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Affiliation(s)
- Allan Pickens
- Emory University, 550 Peachtree Street, NW, Davis Fisher Building, 4th Floor, Atlanta, GA 30308, USA.
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5
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Merritt RE, Abdel-Rasoul M, Fitzgerald M, D'Souza DM, Kneuertz PJ. The Academic Facility Is Associated with Higher Utilization of Esophagectomy and Improved Overall Survival for Esophageal Carcinoma. J Gastrointest Surg 2021; 25:1677-1689. [PMID: 33025288 DOI: 10.1007/s11605-020-04817-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/30/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Operable esophageal carcinoma is potentially curable with surgical resection. The short-term outcomes and overall survival rate for operable esophageal carcinoma may be impacted by the healthcare facility type where patients receive care. METHODS A total of 37, 271 cases with the American Joint Committee on Cancer clinical stage I, II, and III esophageal carcinoma that were reported to the National Cancer Data Base at over 12,721 facilities were analyzed. Healthcare facilities were dichotomized into the community and academic facility types. Marginal multivariable Cox proportional hazard models were used to evaluate differences in overall survival between facility types, which accounted for facility esophageal cancer volume. Propensity score methodology with inverse probability of treatment weighting was used to adjust for patient related baseline differences between facility types. RESULTS Patients with clinical stage I-III esophageal carcinoma who underwent esophagectomy at academic healthcare facilities had a significantly better overall survival compared with patients who underwent esophagectomy at community healthcare facilities [HR = 0.89: CI [0.84-0.95] (p = 0.0005)]. The rate of esophagectomy was significantly higher at the academic facilities (49.0% versus 26.5%; p < 0.0001). The 30-day and 90-day mortality rates for esophagectomy were significantly better for patients who underwent esophagectomy for esophageal cancer at the academic facility types. CONCLUSION Patients with clinical stage I-III esophageal carcinoma who received care at academic facility types had significantly better overall survival compared with community facility types. The utilization of esophagectomy was significantly higher and the short-term surgical outcomes were better for patients treated at academic facility types.
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Affiliation(s)
- Robert E Merritt
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA.
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Morgan Fitzgerald
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Desmond M D'Souza
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Peter J Kneuertz
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA
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Abstract
Newer surgical techniques have reduced complications and mortality following esophagectomy, but they nevertheless remain high. Data regarding complications are frequently inconsistent and, therefore, difficult to compare between groups. As a result, considerable energy is spent trying to identify best practices to minimize complications. This article reviews the rates of complications and attempts to give guidance regarding their management and outcomes.
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Affiliation(s)
- Thomas Fabian
- Section of Thoracic Surgery, Albany Medical College, Third Floor, 50 New Scotland Avenue, Albany, NY 12159, USA.
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7
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Understanding health-seeking and adherence to treatment by patients with esophageal cancer at the Uganda cancer Institute: a qualitative study. BMC Health Serv Res 2021; 21:159. [PMID: 33602201 PMCID: PMC7890846 DOI: 10.1186/s12913-021-06163-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 02/09/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In the low- and middle-income countries, most patients with esophageal cancer present with advanced stage disease and experience poor survival. There is inadequate understanding of the factors that influence decisions to and actual health-seeking, and adherence to treatment regimens among esophageal cancer patients in Uganda, yet this knowledge is critical in informing interventions to promote prompt health-seeking, diagnosis at early stage and access to appropriate cancer therapy to improve survival. We explored health-seeking experiences and adherence to treatment among esophageal cancer patients attending the Uganda Cancer Institute. METHODS We conducted an interview based qualitative study at the Uganda Cancer Institute (UCI). Participants included patients with established histology diagnosis of esophageal cancer and healthcare professionals involved in the care of these patients. We used purposive sampling approach to select study participants. In-depth and key informant interviews were used in data collection. Data collection was conducted till point of data saturation was reached. Thematic content analysis approach was used in data analyses and interpretations. Themes and subthemes were identified deductively. RESULTS Sixteen patients and 17 healthcare professionals were included in the study. Delayed health-seeking and poor adherence to treatment were related to (i) emotional and psychosocial factors including stress of cancer diagnosis, stigma related to esophageal cancer symptoms, and fear of loss of jobs and livelihood, (ii) limited knowledge and recognition of esophageal cancer symptoms by both patients and primary healthcare professionals, and (iii) limited access to specialized cancer care, mainly because of long distance to the facility and associated high transport cost. Patients were generally enthused with patient - provider relationships at the UCI. While inadequate communication and some degree of incivility were reported, majority of patients thought the healthcare professionals were empathetic and supportive. CONCLUSION Health system and individual patient factors influence health-seeking for symptoms of esophageal cancer and adherence to treatment schedule for the disease. Interventions to improve access to and acceptability of esophageal cancer services, as well as increase public awareness of esophageal cancer risk factors and symptoms could lead to earlier diagnosis and potentially better survival from the disease in Uganda.
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8
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Cho JH. Reflux Following Esophagectomy for Esophageal Cancer. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:217-221. [PMID: 32793455 PMCID: PMC7409890 DOI: 10.5090/kjtcs.2020.53.4.217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/09/2020] [Accepted: 07/11/2020] [Indexed: 02/04/2023]
Abstract
Gastroesophageal reflux is a common problem after gastroesophageal resection and reconstruction, despite the routine prescription of proton pump inhibitors (PPIs). Resection of the lower esophageal sphincter and excision of the vagus nerve are generally thought to be the main factors that interfere with gastric motor function. However, physiological studies of reflux symptoms after esophagectomy are still lacking. Gastroesophageal reflux occurs frequently after esophagectomy, but there is no known effective method to prevent it. Therefore, in order to manage gastroesophageal reflux after esophagectomy, strict lifestyle modifications and gastric acid suppression treatment such as PPIs are needed, and further clinical studies are required.
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Affiliation(s)
- Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Chapman BC, Weyant M, Hilton S, Hosokawa PW, McCarter MD, Gleisner A, Nader ND, Gajdos C. Analysis of the National Cancer Database Esophageal Squamous Cell Carcinoma in the United States. Ann Thorac Surg 2019; 108:1535-1542. [PMID: 31302081 DOI: 10.1016/j.athoracsur.2019.05.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Esophageal squamous cell carcinoma (ESCC) has been poorly studied, approached with therapeutic nihilism, and likely undertreated. We studied the impact of clinical and patient factors on the survival of ESCC in the United States. METHODS We selected patients with stage I to III ESCC from 2004 to 2013, using the National Cancer Database. Patients were categorized into the following treatment modalities: (1) definitive chemoradiation therapy (CR), (2) neoadjuvant therapy followed by esophageal resection (ER), (3) ER alone, and (4) ER followed by adjuvant therapy. Our main outcome measure was overall survival. RESULTS We identified 11,229 patients with ESCC undergoing definitive CR (78.6%); neoadjuvant therapy followed by ER (8.5%), ER alone (10.1%), and ER followed by adjuvant therapy (2.6%). Compared with neoadjuvant therapy, both ER alone and definitive CR were associated with substantially increased mortality. Patients treated at high-volume centers (>20), regardless of whether they underwent ER, had improved survival compared with facilities that performed 10 to 19, 5 to 9, and less than 5 ERs per year. CONCLUSIONS Patients treated at high-volume facilities were more likely to receive neoadjuvant therapy, and there was a marked inverse relationship between annual surgical volume and long-term survival for both surgically and non-surgically treated patients with stage I to III ESCC.
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Affiliation(s)
- Brandon C Chapman
- Department of Surgery, University of Colorado at Denver, Aurora, Colorado
| | - Michael Weyant
- Department of Cardiothoracic Surgery, University of Colorado at Denver, Aurora, Colorado
| | - Sarah Hilton
- Department of Surgery, University of Colorado at Denver, Aurora, Colorado
| | - Patrick W Hosokawa
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, Colorado
| | - Martin D McCarter
- Department of Surgery, University of Colorado at Denver, Aurora, Colorado
| | - Ana Gleisner
- Department of Surgery, University of Colorado at Denver, Aurora, Colorado
| | - Nader D Nader
- Department of Anesthesiology, University of New York at Buffalo, Buffalo, New York; Department of Surgery, University of New York at Buffalo, Buffalo, New York
| | - Csaba Gajdos
- Department of Surgery, University of Colorado at Denver, Aurora, Colorado.
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10
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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.
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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
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Can We Increase the Resection Rate by Minimally Invasive Approach? Experience from 100 Minimally Invasive Esophagectomies. JOURNAL OF ONCOLOGY 2019; 2019:3809383. [PMID: 30915119 PMCID: PMC6409017 DOI: 10.1155/2019/3809383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/24/2019] [Accepted: 02/04/2019] [Indexed: 12/21/2022]
Abstract
Background Whether we can increase the resection rate of esophageal cancer by minimally invasive esophagectomy (MIE) is unknown. The aim was to report the number and results of MIE in high-risk patients considered unsuitable for open surgery and compare these results to other operated patients and to high-risk patients not undergoing surgery. Methods At Central Finland Central Hospital, between September 2012 and July 2018, the number of operated MIEs was 100. Of these, 10 patients were prospectively considered unfit for open approach. Nineteen additional high-risk patients with operable disease were ruled out of surgery. The short- and long-term outcomes of these 3 groups were compared. Results In patients eligible for any approach (n=90), MIE only (n=10), and no surgery (n=19), WHO performance status Grade 0 was observed in 66.7%, 20.0%, and 5.3%, respectively; stair climbing with ≥4 stairs was successfully completed in 77.8%, 50%, and 36.8%, respectively. Between any approach and MIE only groups, rate of major complications (Clavien-Dindo ≥3a) was 6.7% vs. 50.0% (p<0.001) without a difference in median hospital stay (9 vs. 10 days, p=0.542). Readmission rates were 4.4% vs. 30.0% (p=0.003). Survival rates were 100% vs. 80% (p<0.001) at 90-days, 91.5% vs. 66.7% (p=0.005) at 1-year, and 68.9% vs. 53.3% (p=0.024) at 3-years, respectively. In comparison between MIE only and no surgery groups, these survival rates from day of diagnosis were 80% vs. 100%, 68.6% vs. 67.1%, and 45.7% vs. 32.0% (p=0.290), respectively. Conclusions By operating patients unsuitable for open approach with MIE, the resection rate increased 11.1%. These high-risk patients had, however, higher early morbidity and reduced long-term survival compared to other operated patients. Though there seems to be long-term benefit of surgery compared to nonsurgical patients, we have to be cautious when offering surgery to those considered unfit for open surgery.
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12
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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 2018; 29:213-217. [PMID: 30362867 DOI: 10.1089/lap.2018.0434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [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.
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Affiliation(s)
- Francisco Schlottmann
- 1 Department of Surgery, University of North Carolina School of Medicine , Chapel Hill, North Carolina.,2 Department of Surgery, Hospital Alemán of Buenos Aires, University of Buenos Aires , Buenos Aires, Argentina
| | - Paula D Strassle
- 1 Department of Surgery, University of North Carolina School of Medicine , Chapel Hill, North Carolina.,3 Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Daniela Molena
- 4 Department of Surgery, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Marco G Patti
- 1 Department of Surgery, University of North Carolina School of Medicine , Chapel Hill, North Carolina.,5 Department of Medicine, University of North Carolina , Chapel Hill, North Carolina
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Nassri A, Zhu H, Muftah M, Ramzan Z. Epidemiology and Survival of Esophageal Cancer Patients in an American Cohort. Cureus 2018; 10:e2507. [PMID: 29930885 PMCID: PMC6007500 DOI: 10.7759/cureus.2507] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objectives This study seeks to delineate trends in esophageal cancer patients in an American cohort and, in particular, examine the impact of race and histology on survival. Methods The association between over 50 variables between histology and race subgroups was evaluated. Survival was calculated using Kaplan-Meier curves and a multivariable Cox regression analysis (MVA) was performed. Results Poorer survival was noted in black vs. white (193 ± 65 days vs. 254 ± 39, 95% CI 205-295, p=0.07) and squamous cell cancer (SCC) vs. adenocarcinoma (AC) (233 ± 24 days vs. 303 ± 48, 95% CI 197-339, p=0.01) patients. In patients with resectable cancer, blacks had poorer survival than whites (253 ± 46 days vs. 538 ± 202, 95% CI 269-603, p=0.03), and SCC had poorer survival than AC (333 ± 58 vs. 638 ± 152 days, 95% CI 306-634, p=0.006). A higher percentage of white patients received surgery compared to black patients (36% vs. 8%, p=0.08). MVA revealed that only surgery was an independent predictor of mortality (p=0.001). Conclusion Black race and SCC were associated with poorer survival. On MVA, surgery was an independent predictor of mortality. Clinicians should be aggressive in offering potentially curative procedures to patients and eliminating socioeconomic barriers.
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Affiliation(s)
- Ammar Nassri
- Department of Medicine Gastroenterology, UF Jacksonville
| | - Hong Zhu
- Department of Clinical Science, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mayssan Muftah
- Department of Internal Medicine, Emory University School of Medicine
| | - Zeeshan Ramzan
- Gastroenterology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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14
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Optimal Therapy in Locally Advanced Esophageal Cancer: a National Cancer Database Analysis. J Gastrointest Surg 2018; 22:187-193. [PMID: 28940160 DOI: 10.1007/s11605-017-3548-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/14/2017] [Indexed: 01/31/2023]
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15
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Yang Y, Jia J, Sun Z, Du F, Yu J, Liu C, Xiao Y, Zhang X. Prognosis impact of clinical characteristics in patients with inoperable esophageal squamous cell carcinoma. PLoS One 2017; 12:e0182660. [PMID: 28783764 PMCID: PMC5546576 DOI: 10.1371/journal.pone.0182660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 07/21/2017] [Indexed: 12/02/2022] Open
Abstract
Background Patients with inoperable esophageal squamous cell carcinoma (ESCC) were not homogeneous and their outcomes were widely divergent. There was a lack of identified clinical factors related to prognosis; and there were no previous studies constructing prognosis score to predict survival and guide treatment. Methods In this retrospective cohort study, twelve clinical characteristics of one hundred and twenty inoperable ESCC patients were collected at diagnosis and analyzed by Cox regression model. Various methods including univariate analysis, confounding adjusted multivariate analysis and model selection were applied to determine factors associated with poor prognosis; and prognosis score was built on established factors. Results Four characters were identified as poor prognosis factors, including mid- and low-thoracic tumor (aHR = 2.20, 95% CI = 1.03, 4.72), abdominal and retroperitoneal lymph node metastasis (aHR = 1.62, 95% CI = 1.00, 2.64), albumin no more than 39g/L (aHR = 2.81, 95% CI = 1.24, 6.41) and hematogenous metastasis (aHR = 1.61, 95% CI = 0.97, 2.69). Patients were stratified into three groups by prognosis score, that was, good survival with none of four identified factors (score zero), poor survival with three to four factors (score three to four) and median with one to two factors (score one to two), survival of three groups were statistically different (ptrend = 0.020). Conclusion Prognosis score based on selected clinical characteristics could predict survival among inoperable ESCC patients, which was critical for individualized treatment and central of precise medicine.
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Affiliation(s)
- Ying Yang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), VIP-II Gastrointestinal Cancer Division of the Department of Medicine, Peking University Cancer Hospital and Institute, Haidian District, Beijing, China
| | - Jun Jia
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), VIP-II Gastrointestinal Cancer Division of the Department of Medicine, Peking University Cancer Hospital and Institute, Haidian District, Beijing, China
| | - Zhiwei Sun
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), VIP-II Gastrointestinal Cancer Division of the Department of Medicine, Peking University Cancer Hospital and Institute, Haidian District, Beijing, China
| | - Feng Du
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), VIP-II Gastrointestinal Cancer Division of the Department of Medicine, Peking University Cancer Hospital and Institute, Haidian District, Beijing, China
| | - Jing Yu
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), VIP-II Gastrointestinal Cancer Division of the Department of Medicine, Peking University Cancer Hospital and Institute, Haidian District, Beijing, China
| | - Chuanling Liu
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), VIP-II Gastrointestinal Cancer Division of the Department of Medicine, Peking University Cancer Hospital and Institute, Haidian District, Beijing, China
| | - Yanjie Xiao
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), VIP-II Gastrointestinal Cancer Division of the Department of Medicine, Peking University Cancer Hospital and Institute, Haidian District, Beijing, China
| | - Xiaodong Zhang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), VIP-II Gastrointestinal Cancer Division of the Department of Medicine, Peking University Cancer Hospital and Institute, Haidian District, Beijing, China
- * E-mail:
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16
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Fabian T, Federico JA. The Impact of Minimally Invasive Esophageal Surgery. Surg Clin North Am 2017; 97:763-770. [DOI: 10.1016/j.suc.2017.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Traveling to a High-volume Center is Associated With Improved Survival for Patients With Esophageal Cancer. Ann Surg 2017; 265:743-749. [PMID: 28266965 DOI: 10.1097/sla.0000000000001702] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND An association between volume and outcomes has been observed for esophagectomy, though little is known about why or how patients choose low- or high-volume centers. The purpose of this study was to evaluate how travel burden and hospital volume influence treatment and outcomes of patients with locally advanced esophageal cancer. METHODS Predictors of receiving esophagectomy for patients with T1-3N1M0 mid or distal esophageal cancer in the National Cancer Data Base from 2006 to 2011 were identified using multivariable logistic regression. Survival was compared using propensity score-matched groups: patients in the bottom quartile of travel distance who underwent treatment at low-volume facilities (Local) and patients in the top quartile of travel distance who underwent treatment at high-volume facilities (Travel). RESULTS Of 4979 patients who met inclusion criteria, we identified 867 Local patients who traveled 2.7 [interquartile range (IQR): 1.6-4 miles] miles to centers that treated 2.6 (IQR: 1.9-3.3) esophageal cancers per year, and 317 Travel patients who traveled 107.1 (IQR: 65-247) miles to centers treating 31.9 (IQR: 30.9-38.5) cases. Travel patients were more likely to undergo esophagectomy (67.8% vs 42.9%, P < 0.001) and had significantly better 5-year survival (39.8% vs 20.6%, P < 0.001) than Local patients. CONCLUSIONS Patients who travel longer distances to high-volume centers have significantly different treatment and better outcomes than patients who stay close to home at low-volume centers. Strategies that support patient travel for treatment at high-volume centers may improve esophageal cancer outcomes.
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Moreno AC, Verma V, Hofstetter WL, Lin SH. Patterns of Care and Treatment Outcomes of Elderly Patients with Stage I Esophageal Cancer: Analysis of the National Cancer Data Base. J Thorac Oncol 2017; 12:1152-1160. [PMID: 28455149 DOI: 10.1016/j.jtho.2017.04.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 03/12/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION This study analyzes practice patterns, treatment-related mortality, survival, and predictors thereof in elderly patients with early-stage esophageal cancer (EC). METHODS The National Cancer Data Base was queried for cT1-2 N0 EC in patients 80 years of age and older. Patients were divided into four treatment groups: observation (Obs), chemoradiotherapy (CRT), local excision (LE), and esophagectomy (Eso). Patient, tumor, and treatment parameters were extracted and compared. Analyses were performed on overall survival (OS) and postoperative 30- and 90-day mortality. RESULTS A total of 923 patients from 2004 to 2012 were analyzed. Of these, 43% underwent clinical Obs, 22% underwent CRT, 25% underwent LE, and 10% underwent Eso. Patients undergoing Obs were older, had more comorbidities, were treated at nonacademic centers, and lived 25 miles or less from the facility. Patients receiving an operation (Eso or LE) were more often younger, male, white, and in the top income quartile. The postoperative 30-day mortality rates in the LE and Eso groups were 1.3% and 9.6%, respectively (p < 0.001) and increased to 2.6% and 20.2% at 90 days, respectively (p < 0.001). The 5-year OS rate was 7% for Obs, 20% for CRT, 33% for LE, and 45% for Eso (p < 0.001). Multivariate analyses showed improved OS with any local definitive therapy: CRT (hazard ratio [HR] = 0.42, 95% confidence interval [CI]: 0.34-0.52, p < 0.001), LE (HR = 0.3, 95% CI: 0.24-0.38, p < 0.001), and Eso (HR = 0.32, 95% CI: 0.23-0.44, p < 0.001). CONCLUSIONS There are noteworthy demographic, socioeconomic, and regional disparities influencing management of elderly patients with stage I EC. Despite high rates of Obs, careful consideration of all local therapy options is warranted, given the improved outcomes with treatment.
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Affiliation(s)
- Amy C Moreno
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Wayne L Hofstetter
- Department of Thoracic Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas.
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Esophageal Cancer Treatment Is Underutilized Among Elderly Patients in the USA. J Gastrointest Surg 2017; 21:126-136. [PMID: 27527093 PMCID: PMC5637537 DOI: 10.1007/s11605-016-3229-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/25/2016] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Large numbers of elderly patients in the USA receive no treatment for esophageal cancer, despite evidence that multimodality treatment can increase survival. Our goal is to identify factors that may contribute to lack of treatment. MATERIALS AND METHODS Using Surveillance Epidemiology and End Results (SEER)-Medicare Linked Database (2001-2009), we identified regional esophageal cancer patients ≥65 years old. Treatment was defined as receiving any medical or surgical therapy for esophageal cancer. Logistic regression analysis was performed to identify factors associated with failure to receive treatment. Overall survival (OS) was analyzed using the Kaplan-Meier method and Cox proportional hazard model. RESULTS There were 5072 patients (median age, 75 years; interquartile range (IQR), 71-81 years). Majority were treated with definitive chemoradiation (48.49 %). Factors associated with lack of treatment included West geographic region and ≥80 years old. Patients who received therapy had better OS (log-rank, p < 0.001). Compared with treated patients, non-treated patients had worse adjusted OS (HR, 1.43; 95 % confidence interval (CI), 1.33-1.55; p < 0.001). CONCLUSIONS Elderly patients with locally advanced esophageal cancer who received treatment had improved 5-year survival compared with patients without treatment. Disparities in utilization of treatment are associated with regional and socioeconomic factors, not presence of comorbidities.
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20
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Taylor LJ, Greenberg CC, Lidor AO, Leverson GE, Maloney JD, Macke RA. Utilization of surgical treatment for local and locoregional esophageal cancer: Analysis of the National Cancer Data Base. Cancer 2016; 123:410-419. [PMID: 27680893 DOI: 10.1002/cncr.30368] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 08/25/2016] [Accepted: 09/08/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Previous studies have suggested that esophagectomy is severely underused for patients with resectable esophageal cancer. The recent expansion of endoscopic local therapies, advances in surgical techniques, and improved postoperative outcomes have changed the therapeutic landscape. The impact of these developments and evolving treatment guidelines on national practice patterns is unknown. METHODS Patients diagnosed with clinical stage 0 to III esophageal cancer were identified from the National Cancer Database (2004-2013). The receipt of potentially curative surgical treatment over time was analyzed, and multivariate logistic regression was used to identify factors associated with surgical treatment. RESULTS The analysis included 52,122 patients. From 2004 to 2013, the overall rate of potentially curative surgical treatment increased from 36.4% to 47.4% (P < .001). For stage 0 disease, the receipt of esophagectomy decreased from 23.8% to 17.9% (P < .001), whereas the use of local therapies increased from 34.3% to 58.8% (P < .001). The use of surgical treatment increased from 43.4% to 61.8% (P < .001), from 36.1% to 45.0% (P < .001), and from 30.8% to 38.6% (P < .001) for patients with stage I, II, and III disease, respectively. In the multivariate analysis, divergent practice patterns and adherence to national guidelines were noted between academic and community facilities. CONCLUSIONS The use of potentially curative surgical treatment has increased for patients with stage 0 to III esophageal cancer. The expansion of local therapies has driven increased rates of surgical treatment for early-stage disease. Although the increased use of esophagectomy for more advanced disease is encouraging, significant variation persists at the patient and facility levels. Cancer 2017;123:410-419. © 2016 American Cancer Society.
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Affiliation(s)
- Lauren J Taylor
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | | | - Anne O Lidor
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Glen E Leverson
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - James D Maloney
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Ryan A Macke
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
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21
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Cummings LC, Kou TD, Schluchter MD, Chak A, Cooper GS. Outcomes after endoscopic versus surgical therapy for early esophageal cancers in an older population. Gastrointest Endosc 2016; 84:232-240.e1. [PMID: 26801375 PMCID: PMC4949078 DOI: 10.1016/j.gie.2016.01.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 01/05/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic treatment of early esophageal cancer provides an alternative to esophagectomy, which older patients may not tolerate. Population-based data regarding short-term outcomes and recurrence after endoscopic treatment for esophageal cancer are limited. We compared short-term outcomes, treated recurrence, and survival after endoscopic versus surgical therapy for early esophageal cancers in an older population. METHODS We conducted a retrospective cohort study identifying patients aged ≥66 years with Tis or T1a tumors without nodal involvement diagnosed from 1994 to 2011 from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. RESULTS Of 2193 patients, 41% (n = 893) underwent esophagectomy, and 12% (n = 255) underwent endoscopic treatment within 6 months of diagnosis. Those treated endoscopically were older and more likely to have a Charlson comorbidity score ≥2. A composite endpoint, hospitalization and/or adverse events at 60 days, was higher in surgical patients than in the endoscopic treatment group (30% vs 12%; P < .001). In a Cox model stratified by histology, adjusting for other factors, endoscopic treatment was associated with improved 2-year survival (hazard ratio 0.51; 95% CI, 0.36-0.73). CONCLUSIONS In this older population, a composite short-term endpoint was worse in the surgical group. Endoscopic treatment was associated with improved survival through 2 years. These results suggest that endoscopic treatment is a reasonable approach for early esophageal cancers in the elderly.
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Affiliation(s)
- Linda C. Cummings
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
- Case Western Reserve University, Cleveland, Ohio
| | - Gregory S. Cooper
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
- Case Western Reserve University, Cleveland, Ohio
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22
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Worni M, Castleberry AW, Gloor B, Pietrobon R, Haney JC, D’Amico TA, Akushevich I, Berry MF. Trends and outcomes in the use of surgery and radiation for the treatment of locally advanced esophageal cancer: a propensity score adjusted analysis of the surveillance, epidemiology, and end results registry from 1998 to 2008. Dis Esophagus 2014; 27:662-9. [PMID: 23937253 PMCID: PMC3923844 DOI: 10.1111/dote.12123] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We examined outcomes and trends in surgery and radiation use for patients with locally advanced esophageal cancer, for whom optimal treatment isn't clear. Trends in surgery and radiation for patients with T1-T3N1M0 squamous cell or adenocarcinoma of the mid or distal esophagus in the Surveillance, Epidemiology, and End Results database from 1998 to 2008 were analyzed using generalized linear models including year as predictor; Surveillance, Epidemiology, and End Results doesn't record chemotherapy data. Local treatment was unimodal if patients had only surgery or radiation and bimodal if they had both. Five-year cancer-specific survival (CSS) and overall survival (OS) were analyzed using propensity-score adjusted Cox proportional-hazard models. Overall 5-year survival for the 3295 patients identified (mean age 65.1 years, standard deviation 11.0) was 18.9% (95% confidence interval: 17.3-20.7). Local treatment was bimodal for 1274 (38.7%) and unimodal for 2021 (61.3%) patients; 1325 (40.2%) had radiation alone and 696 (21.1%) underwent only surgery. The use of bimodal therapy (32.8-42.5%, P = 0.01) and radiation alone (29.3-44.5%, P < 0.001) increased significantly from 1998 to 2008. Bimodal therapy predicted improved CSS (hazard ratios [HR]: 0.68, P < 0.001) and OS (HR: 0.58, P < 0.001) compared with unimodal therapy. For the first 7 months (before survival curve crossing), CSS after radiation therapy alone was similar to surgery alone (HR: 0.86, P = 0.12) while OS was worse for surgery only (HR: 0.70, P = 0.001). However, worse CSS (HR: 1.43, P < 0.001) and OS (HR: 1.46, P < 0.001) after that initial timeframe were found for radiation therapy only. The use of radiation to treat locally advanced mid and distal esophageal cancers increased from 1998 to 2008. Survival was best when both surgery and radiation were used.
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Affiliation(s)
- Mathias Worni
- Department of Surgery, Duke University Medical Center, Durham NC, USA,Department of Visceral Surgery and Medicine, University of Bern, Inselspital, Bern, Switzerland
| | | | - Beat Gloor
- Department of Visceral Surgery and Medicine, University of Bern, Inselspital, Bern, Switzerland
| | - Ricardo Pietrobon
- Department of Surgery, Duke University Medical Center, Durham NC, USA
| | - John C. Haney
- Department of Surgery, Duke University Medical Center, Durham NC, USA
| | - Thomas A. D’Amico
- Department of Surgery, Duke University Medical Center, Durham NC, USA
| | - Igor Akushevich
- Center for Population Health and Aging, Duke University, Durham NC, USA
| | - Mark F. Berry
- Department of Surgery, Duke University Medical Center, Durham NC, USA
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Berry MF. Esophageal cancer: staging system and guidelines for staging and treatment. J Thorac Dis 2014; 6 Suppl 3:S289-97. [PMID: 24876933 DOI: 10.3978/j.issn.2072-1439.2014.03.11] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 03/05/2014] [Indexed: 12/25/2022]
Abstract
Survival of esophageal cancer is improving but remains poor. Esophageal cancer stage is based on depth of tumor invasion, involvement of regional lymph nodes, and the presence or absence of metastatic disease. Appropriate work-up is critical to identify accurate pre-treatment staging so that both under-treatment and unnecessary treatment is avoided. Treatment strategy should follow guideline recommendations, and generally should be developed after multidisciplinary evaluation.
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Affiliation(s)
- Mark F Berry
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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24
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Takassi GF, Herbella FAM, Patti MG. [Anatomic variations in the surgical anatomy of the thoracic esophagus and its surrounding structures]. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2013; 26:101-6. [PMID: 24000020 DOI: 10.1590/s0102-67202013000200006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 01/15/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Esophagectomy is a challenging procedure due to: a) it is a complex operation; b) it is linked to very high morbidity and mortality rates; c) surgical anatomy of the esophagus is very peculiar. The anatomic variations that can be unexpectedly found during an operation may cause complications and influence the outcome. AIM To review the anatomic basis for esophagectomy focusing on anatomic variations found in the mediastinal structures based on literature review and cadaver dissection. METHODS Literature related to the surgical anatomy of the esophagus and mediastinal structures was reviewed. Also, a total of 20 fresh (non-embalmed, non-preserved, time of death under 12 h) human cadavers were dissected. There were 16 male and mean age was 53 ± 23 years. RESULTS Anatomic variations for aorta, azygos system, pleura, vagus nerve, lymph nodes and thoracic duct were documented. CONCLUSIONS The organs and structures of the mediastinum may frequently present anatomic variations. Some of these may be clinically significant during an esophagectomy. Because only a part of them may be identified before the operation with the current imaging tools, surgeons must be aware of these anatomic variations.
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Affiliation(s)
- Guilherme F Takassi
- Departamento de Cirurgia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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25
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Dubecz A, Solymosi N, Schweigert M, Stadlhuber RJ, Peters JH, Ofner D, Stein HJ. Time trends and disparities in lymphadenectomy for gastrointestinal cancer in the United States: a population-based analysis of 326,243 patients. J Gastrointest Surg 2013; 17:611-8; discussion 618-9. [PMID: 23340992 DOI: 10.1007/s11605-013-2146-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Accepted: 01/04/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND The value of lymphadenectomy in most localized gastrointestinal (GI) malignancies is well established. Our objectives were to evaluate the time trends of lymphadenectomy in GI cancer and identify factors associated with inadequate lymphadenectomy in a large population-based sample. METHODS Using the National Cancer Institute's Surveillance Epidemiology and End Results Database (1998-2009), a total of 326,243 patients with surgically treated GI malignancy (esophagus, 13,165; stomach, 18,858; small bowel, 7,666; colon, 232,345; rectum, 42,338; pancreas, 12,141) were identified. Adequate lymphadenectomy was defined based on the National Cancer Center Network's recommendations as more than 15 esophagus, 15 stomach, 12 small bowel, 12 colon, 12 rectum, and 15 pancreas. The median number of lymph nodes removed and the prevalence of adequate and/or no lymphadenectomy for each cancer type were assessed and trended over the ten study years. Multivariate logistic regression was employed to identify factors predicting adequate lymphadenectomy. RESULTS The median number of excised nodes improved over the decade of study in all types of cancer: esophagus, from 7 to 13; stomach, 8-12; small bowel, 2-7; colon, 9-16; rectum, 8-13; and pancreas, 7-13. Furthermore, the percentage of patients with an adequate lymphadenectomy (49 % for all types) steadily increased, and those with zero nodes removed (6 % for all types) steadily decreased in all types of cancer, although both remained far from ideal. By 2009, the percentages of patients with adequate lymphadenectomy were 43 % for esophagus, 42 % for stomach, 35 % for small intestine, 77 % for colon, 61 % for rectum, and 42 % for pancreas. Men, patients >65 years old, or those undergoing surgical therapy earlier in the study period and living in areas with high poverty rates were significantly less likely to receive adequate lymphadenectomy (all p < 0.0001). CONCLUSIONS Lymph node retrieval during surgery for GI cancer remains inadequate in a large proportion of patients in the USA, although the median number of resected nodes increased over the last 10 years. Gender and socioeconomic disparities in receiving adequate lymphadenectomy were observed.
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Affiliation(s)
- A Dubecz
- Department of Surgery, Klinikum Nürnberg, Prof. Ernst-Nathan Str. 1, 90419, Nuremberg, Germany.
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Murphy CC, Hofstetter WL, Correa AM, Ajani JA, Komaki RU, Swisher SG. Utilization of surgery in trimodality-eligible patients with locally advanced esophageal adenocarcinoma in a nonprotocol setting. Dis Esophagus 2013; 26:708-15. [PMID: 23350713 DOI: 10.1111/dote.12019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Trimodality therapy with neoadjuvant chemoradiation followed by surgery significantly improves the survival of locally advanced (clinical stage IIA-III) esophageal cancer patients compared to treatment with surgery alone. This has resulted in an increased use of neoadjuvant therapy in recent years, yet little is known regarding how this increase has impacted the utilization of surgery in the treatment of locally advanced disease. Although previous reports of experimental protocols suggest that 90-95% of patients complete trimodality therapy including a surgical resection, trimodality therapy completion among adenocarcinoma patients eligible for curative resection has not been evaluated in a nonprotocol setting. We sought to (i) assess the completion of trimodality therapy among locally advanced esophageal adenocarcinoma patients; (ii) characterize the reasons for avoiding surgery; and (iii) identify factors associated with failure to complete trimodality therapy. We identified 296 patients with locally advanced esophageal adenocarcinoma eligible for trimodality therapy at our institution. All patients were evaluated in a multidisciplinary setting and considered eligible for curative resection after initial staging and physiologic assessment. Multivariable logistic regression was used to identify factors associated with failure to complete trimodality therapy. Of 296 trimodality-eligible patients, 33% (97/296) did not complete trimodality therapy. Reasons for not undergoing surgery included patient choice (27.8%, 27/97), distant progression of disease during chemoradiation (23.7%, 23/97), and physician preference for surveillance (23.7%, 23/97). In addition, 17.5% (17/97) of patients had physical deterioration in performance status, and treatment-related deaths occurred in 7.2% (7/97) prior to surgery. In the total study population (n = 296), multivariable logistic regression identified older age (≥70 years: odds ratio [OR] = 6.611, 95% confidence interval [CI]: 2.900-15.071), pretreatment standard uptake value (6.8-10.1: OR = 2.393, 95% CI: 1.050-5.455; ≥15.8: OR = 3.623, 95% CI: 1.604-8.186), and a radiation dose of 50.4 Gy (OR = 5.312, 95% CI: 2.365-11.929) as being significantly associated with failure to complete trimodality therapy. Among the subgroup of patients that successfully completed chemoradiation (n = 266), older patients (≥70 years: OR = 9.606, 95% CI: 3.637-25.372), those with a comorbidity score of 2 or higher (OR = 4.059, 95% CI: 1.257-13.103), and those that received a radiation dose of 50.4 Gy (OR = 4.878, 95% CI: 1.974-12.054) were at a significantly higher risk of not completing trimodality therapy. Trimodality therapy completion among patients with locally advanced esophageal adenocarcinoma in a nonprotocol setting is considerably lower than what has previously been reported in clinical trials. Our findings suggest that a selective approach to surgery is commonly utilized in clinical practice. Trimodality-eligible patients that are older and have a higher comorbidity score are at risk for not completing trimodality therapy.
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Affiliation(s)
- C C Murphy
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center; University of Texas School of Public Health, Houston, Texas, USA
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Worni M, Martin J, Gloor B, Pietrobon R, D'Amico TA, Akushevich I, Berry MF. Does surgery improve outcomes for esophageal squamous cell carcinoma? An analysis using the surveillance epidemiology and end results registry from 1998 to 2008. J Am Coll Surg 2012; 215:643-51. [PMID: 23084493 DOI: 10.1016/j.jamcollsurg.2012.07.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 07/07/2012] [Accepted: 07/13/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND We examined survival associated with locally advanced esophageal squamous cell cancer (SCC) to evaluate if treatment without surgery could be considered adequate. STUDY DESIGN Patients in the Surveillance, Epidemiology and End Results Registry (SEER) registry with stage II-III SCC of the mid or distal esophagus from 1998-2008 were grouped by treatment with definitive radiation versus esophagectomy with or without radiation. Information on chemotherapy is not recorded in SEER. Tumor stage was defined as first clinical tumor stage in case of neo-adjuvant therapy and pathological report if no neo-adjuvant therapy was performed. Cancer-specific (CSS) and overall survival (OS) were analyzed using the Kaplan-Meier approach and propensity-score adjusted Cox proportional hazard models. RESULTS Of the 2,431 patients analyzed, there were 844 stage IIA (34.7%), 428 stage IIB (17.6%), 1,159 stage III (47.7%) patients. Most were treated with definitive radiation (n = 1,426, 58.7%). Of the 1,005 (41.3%) patients who underwent surgery, 369 (36.7%) had preoperative radiation, 160 (15.9%) had postoperative radiation, and 476 (47.4%) had no radiation. Five-year survival was 17.9% for all patients, and 22.1%, 18.5%, and 14.5% for stages IIA, IIB, and stage III, respectively. Compared to treatment that included surgery, definitive radiation alone predicted worse propensity-score adjusted survival for all patients (CSS Hazard Ratio [HR] 1.48, p < 0.001; OS HR 1.46, p < 0.001) and for stage IIA, IIB, and III patients individually (all p values ≤ 0.01). Compared to surgery alone, surgery with radiation predicted improved survival for stage III patients (CSS HR 0.62, p = 0.001, OS HR 0.62, p < 0.001) but not stage IIA or IIB (all p values > 0.18). CONCLUSIONS Esophagectomy is associated with improved survival for patients with locally advanced SCC and should be considered as an integral component of the treatment algorithm if feasible.
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Affiliation(s)
- Mathias Worni
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Villaflor VM, Allaix ME, Minsky B, Herbella FA, Patti MG. Multidisciplinary approach for patients with esophageal cancer. World J Gastroenterol 2012; 18:6737-46. [PMID: 23239911 PMCID: PMC3520162 DOI: 10.3748/wjg.v18.i46.6737] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 11/19/2012] [Accepted: 11/24/2012] [Indexed: 02/06/2023] Open
Abstract
Patients with esophageal cancer have a poor prognosis because they often have no symptoms until their disease is advanced. There are no screening recommendations for patients unless they have Barrett's esophagitis or a significant family history of this disease. Often, esophageal cancer is not diagnosed until patients present with dysphagia, odynophagia, anemia or weight loss. When symptoms occur, the stage is often stage III or greater. Treatment of patients with very early stage disease is fairly straight forward using only local treatment with surgical resection or endoscopic mucosal resection. The treatment of patients who have locally advanced esophageal cancer is more complex and controversial. Despite multiple trials, treatment recommendations are still unclear due to conflicting data. Sadly, much of our data is difficult to interpret due to many of the trials done have included very heterogeneous groups of patients both histologically as well as anatomically. Additionally, studies have been underpowered or stopped early due to poor accrual. In the United States, concurrent chemoradiotherapy prior to surgical resection has been accepted by many as standard of care in the locally advanced patient. Patients who have metastatic disease are treated palliatively. The aim of this article is to describe the multidisciplinary approach used by an established team at a single high volume center for esophageal cancer, and to review the literature which guides our treatment recommendations.
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Zeng J, Liu JS. Quality of life after three kinds of esophagectomy for cancer. World J Gastroenterol 2012; 18:5106-13. [PMID: 23049222 PMCID: PMC3460340 DOI: 10.3748/wjg.v18.i36.5106] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 05/08/2012] [Accepted: 05/13/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate quality of life (QOL) following Ivor Lewis, left transthoracic, and combined thoracoscopic/laparoscopic esophagectomy in patients with esophageal cancer.
METHODS: Ninety patients with esophageal cancer were assigned to Ivor Lewis (n = 30), combined thoracoscopic/laparoscopic (n = 30), and left transthoracic (n = 30) esophagectomy groups. The QOL-core 30 questionnaire and the supplemental QOL-esophageal module 18 questionnaire for patients with esophageal cancer, both developed by the European Organization for Research and Treatment of Cancer, were used to evaluate patients’ QOL from 1 wk before to 24 wk after surgery.
RESULTS: A total of 324 questionnaires were collected from 90 patients; 36 postoperative questionnaires were not completed because patients could not be contacted for follow-up visits. QOL declined markedly in all patients at 1 wk postoperatively: preoperative and 1-wk postoperative global QOL scores in the Ivor Lewis, combined thoracoscopic/laparoscopic, and left transthoracic groups were 80.8 ± 9.3 vs 32.0 ± 16.1 (P < 0.001), 81.1 ± 9.0 vs 53.3 ± 11.5 (P < 0.001), and 83.6 ± 11.2 vs 46.4 ± 11.3 (P < 0.001), respectively. Thereafter, QOL recovered gradually in all patients. Patients who underwent Ivor Lewis esophagectomy showed the most pronounced decline in QOL; global scores were lower in this group than in the combined thoracoscopic/laparoscopic (P < 0.001) and left transthoracic (P < 0.001) groups at 1 wk postoperatively and was not restored to the preoperative level at 24 wk postoperatively. QOL declined least in patients undergoing combined thoracoscopic/laparoscopic esophagectomy, and most indices had recovered to preoperative levels at 24 wk postoperatively. In the Ivor Lewis and combined thoracoscopic/laparoscopic groups, pain and physical function scores were 78.9 ± 18.5 vs 57.8 ± 19.9 (P < 0.001) and 59.3 ± 16.1 vs 70.2 ± 19.2 (P = 0.02), respectively, at 1 wk postoperatively and 26.1 ± 28.6 vs 9.5 ± 15.6 (P = 0.007) and 88.4 ± 10.5 vs 95.8 ± 7.3 (P = 0.003), respectively, at 24 wk postoperatively. Scores in the left transthoracic esophagectomy group fell between those of the other two groups.
CONCLUSION: Compared with Ivor Lewis and left transthoracic esophagectomies, combined thoracoscopic/laparoscopic esophagectomy enables higher postoperative QOL, making it a preferable surgical approach for esophageal cancer.
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Mezhir JJ, McDowell BD. Pancreaticobiliary surgery for the treatment of malignancy: spread the word. J Surg Res 2012; 185:513-5. [PMID: 23043864 DOI: 10.1016/j.jss.2012.09.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 08/29/2012] [Accepted: 09/10/2012] [Indexed: 11/18/2022]
Affiliation(s)
- James J Mezhir
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
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Merkow RP, Bilimoria KY, McCarter MD, Chow WB, Gordon HS, Stewart AK, Ko CY, Bentrem DJ. Effect of histologic subtype on treatment and outcomes for esophageal cancer in the United States. Cancer 2011; 118:3268-76. [PMID: 22006369 DOI: 10.1002/cncr.26608] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 07/28/2011] [Accepted: 08/09/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Esophageal adenocarcinoma (AC) and squamous cell carcinoma (SCC) have distinct clinico-pathologic characteristics; however, it is unclear whether treatment patterns differ by histologic subtype. The objective of this study was to examine differences in treatment use and outcomes by histologic subtype for esophageal cancer in the United States. METHODS From the National Cancer Data Base, patients with esophageal cancer were identified. Regression models were formulated to assess the influence of histologic subtype on treatment use and overall survival. RESULTS From 1998 to 2007, 80,961 patients were identified with esophageal cancer in the United States. A higher percentage of patients with nonmetastatic AC underwent surgical resection compared with patients with nonmetastatic SCC (AC, 65.7%; SCC, 36.0%; P<.001), who were more often treated with chemoradiotherapy alone (AC, 25.7%; SCC, 54.1%; P<.001). High-volume academic centers used surgery more frequently for both AC and SCC than did other centers, yet even at high-volume academic centers, surgery was used much less often to treat SCC than AC (AC, 79.3%; SCC, 53.7%; P<.001). The likelihood of operative treatment for nonmetastatic disease was significantly lower in patients with SCC compared with patients with AC (P<.001). Overall survival was lower for patients with stage II/III disease of either histologic subtype treated with chemoradiotherapy alone compared with surgery plus chemoradiotherapy (P<.001). CONCLUSION A large proportion of patients with esophageal cancer are being treated nonoperatively, and treatment use varies according to tumor histology, particularly by center type.
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Affiliation(s)
- Ryan P Merkow
- Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.
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Aghcheli K, Marjani HA, Nasrollahzadeh D, Islami F, Shakeri R, Sotoudeh M, Abedi-Ardekani B, Ghavamnasiri MR, Razaei E, Khalilipour E, Mohtashami S, Makhdoomi Y, Rajabzadeh R, Merat S, Sotoudehmanesh R, Semnani S, Malekzadeh R. Prognostic factors for esophageal squamous cell carcinoma--a population-based study in Golestan Province, Iran, a high incidence area. PLoS One 2011; 6:e22152. [PMID: 21811567 PMCID: PMC3141005 DOI: 10.1371/journal.pone.0022152] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 06/17/2011] [Indexed: 02/07/2023] Open
Abstract
Golestan Province in northern Iran is an area with a high incidence of esophageal squamous cell carcinoma (ESCC). We aimed to investigate prognostic factors for ESCC and survival of cases in Golestan, on which little data were available. We followed-up 426 ESCC cases participating in a population-based case-control study. Data were analyzed using the Kaplan–Meier method and the Cox proportional hazard models. Median survival was 7 months. Age at diagnosis was inversely associated with survival, but the association was disappeared with adjustment for treatment. Residing in urban areas (hazard ratio, HR = 0.70; 95% CI 0.54–0.90) and being of non-Turkmen ethnic groups (HR = 0.76; 95% CI 0.61–0.96) were associated with better prognosis. In contrast to other types of tobacco use, nass (a smokeless tobacco product) chewing was associated with a slightly poorer prognosis even in models adjusted for other factors including stage of disease and treatment (HR = 1.38; 95% CI 0.99–1.92). Opium use was associated with poorer prognosis in crude analyses but not in adjusted models. Almost all of potentially curative treatments were associated with longer survival. Prognosis of ESCC in Golestan is very poor. Easier access to treatment facilities may improve the prognosis of ESCC in Golestan. The observed association between nass chewing and poorer prognosis needs further investigations; this association may suggest a possible role for ingestion of nass constituents in prognosis of ESCC.
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Affiliation(s)
- Karim Aghcheli
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Haji-Amin Marjani
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Dariush Nasrollahzadeh
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Farhad Islami
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- International Agency for Research on Cancer, Lyon, France
| | - Ramin Shakeri
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Sotoudeh
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnoush Abedi-Ardekani
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Ezzatollah Razaei
- Department of Oncology, Omid Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elias Khalilipour
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Samira Mohtashami
- Department of Oncology, Omid Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Yasha Makhdoomi
- Department of Oncology, Omid Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Rabea Rajabzadeh
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Merat
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Rasoul Sotoudehmanesh
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahryar Semnani
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Reza Malekzadeh
- Digestive Disease Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- * E-mail:
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