The Effect of Neoadjuvant Therapy on Esophagectomy for cT2N0M0 Esophageal Adenocarcinoma

Comparison of long-term survival of neoadjuvant therapy plus surgery versus upfront surgery and the role of adjuvant therapy for T1b-2N0-1 esophageal cancer: a population study of the SEER database and Chinese cohort

BACKGROUND

For stage T1b-2N0-1 esophageal cancer, the impact of neoadjuvant therapy plus surgery (NS), surgery alone (SA), and surgery plus adjuvant therapy (ST) on cancer-specific survival (CSS) and overall survival (OS) is uncertain.

METHODS

Stage T1b-2N0-1 esophageal cancer patients from the SEER database and two Chinese cancer centers were included in this study. The Kaplan-Meier method was used to plot survival curves, which were compared using the log-rank test. Propensity score matching was used to equalize differences between the groups. Cox proportional hazards regression models were used to analyze prognostic factors. A nomogram for OS was developed after screening the variables using the Cox proportional hazards regression model and the least absolute shrinkage and selection operator. The performance of the nomogram was assessed by the Harrell concordance index (C-index), the area under the curve (AUC) of the receiver operating characteristic curve, calibration plots, and decision curve analysis.

RESULTS

After propensity score matching analysis, the 3-year CSS and OS rates in the NS group compared to the SA group were 80.3% versus 62.1% ( P =0.016) and 75.8% versus 55.5% ( P =0.006), the 3-year CSS and OS rates in the NS group compared to the ST group were 71.3% versus 68.3% ( P =0.560) and 69.8% versus 62.9% ( P =0.330), the 3-year CSS and OS rates in the SA group compared to the ST group were 54.6% versus 66.7% ( P =0.220) and 50.2% versus 57.9% ( P =0.290), respectively. The predictive nomogram for OS in T1b-2N0-1 patients ultimately incorporated five clinicopathological variables: T stage, N stage, age, examined lymph nodes, and therapy modality. The nomogram C-index for predicting OS was 0.648, 0.663, and 0.666 in the training group, external validation group-1, and external validation group-2, respectively. The 1-year, 3-year, and 5-year predicted AUC values of the OS prediction model were 0.659, 0.639, and 0.612 for the training group, and 0.786, 0.758, and 0.692 for validation group-1, and 0.805, 0.760, and 0.693 for validation group-2, respectively.

CONCLUSION

For patients with stage T1b-2N0-1 esophageal cancer, neoadjuvant therapy significantly improves prognosis compared to surgery alone, those presenting with positive lymph nodes after upfront surgery can achieve survival benefits from adjuvant therapy.

Do socioeconomic factors impair uptake of neoadjuvant therapy for patients with locoregional oesophageal cancer?

OBJECTIVES

The benefits of neoadjuvant therapy prior to surgery for patients with locally advanced oesophageal cancer have been well established by multiple trials. However, there may be socioeconomic barriers impacting equitable administration. We aim to identify whether disparities exist in the uptake of neoadjuvant therapy among patients with loco-regional oesophageal cancer.

METHODS

We queried the National Cancer Database to identify patients with clinical stage II-III oesophageal cancer who underwent surgical resection (2006-2020). Logistic regression was performed to identify associations between sociodemographic factors and uptake of neoadjuvant therapy. In propensity score-matched groups, survival was evaluated using the Kaplan-Meier method.

RESULTS

Among 19 748 clinical stage II-III patients, 85% (n = 16 781) received neoadjuvant therapy and 15% (n = 2967) underwent upfront surgery. Rates of neoadjuvant uptake increased over time. On multivariable analysis after adjusting by clinical stage, factors associated with lower rates of neoadjuvant therapy included older age (age ≥70, adjusted odds ratio 0.52; 95% confidence interval 0.47-0.57; P < 0.001), female sex (0.76; 0.69-0.85; P < 0.001), Black race (0.77; 0.63-0.94; P = 0.009), more comorbidities (0.76; 0.65-0.85; P < 0.001) and government rather than private insurance (0.84; 0.76-0.93; P < 0.001). In a propensity-matched cohort accounting for these variables, neoadjuvant treatment was associated with improved 5-year overall survival compared to upfront surgery (41.1% vs 35.4%, P < 0.001).

CONCLUSIONS

Several sociodemographic factors are associated with the delivery of neoadjuvant therapy in patients with oesophageal cancer, including age, sex, race, and insurance status. Interventions can be put into place to target vulnerable patients and ensure equitable delivery of care.