Contemporary trends and survival outcomes of females with esophageal cancer in the United States

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Background: Esophageal cancer (EC) is historically a male dominant disease. Current evidence on the impact of gender on clinical presentation and survival outcomes of EC is limited by small sample size or single institution series. Methods: Patients with EC (stage I-III) were identified in the NCDB (2004-2016). Clinicopathologic and treatment characteristics of male and female patients were compared using Chi-square analysis. Kaplan-Meier and Cox multivariable regression were used to estimate overall survival (OS). Results: Of 62,893 patients included, most patients were male (77.7%). Adenocarcinoma was the most common subtype (66.7%). Squamous cell carcinoma was more predominant in females (57.1% vs. 26.5%, p<0.001). Females were older (68.5 vs. 66.1 yrs; p<0.001) and more likely African American (AA, 14% vs. 8.1%; p<0.001). Females presented with more local disease (stage I, 19.6% vs. 18.2%; p<0.001) while males presented with more locoregional disease (LRD, stage II/III, 80.4% vs 81.8%, p<0.001). Of those with LRD, females less frequently received chemotherapy (CT, 75.4% vs. 82.9%, p<0.001), radiation therapy (RT, 78.9% vs. 82.6%, p<0.001), and esophagectomy (EG, 28% vs. 40.5%, p<0.001). White females with LRD received less CT (76.2% vs. 83.9%, p<0.001), RT (79.5% vs. 83.3%, p<0.001), and EG (30.6% vs. 43.5%, p<0.001). AA females with LRD received less CT (71.9% vs. 75.2%, p=0.013) and RT (77.4% vs. 80.5%, p=0.013) but had similar rates of EG as AA males (p=0.476). Females had worse OS than males (18.1 vs. 19.7mo, p=0.001; cI: 23.5 vs. 31.9mo, p<0.001; LRD: 17.2 vs 18.3mo, p=0.473). White females had worse OS than white males (18.6 vs. 20.4mo, p<0.001) while AA females had better OS (13.5 vs. 12.6mo, p=0.001). White females who underwent EG had improved OS over white males (47.6 vs 38mo, p<0.001) while AA males and females who underwent EG had similar OS (p=0.473). Female gender, older age, AA race, high comorbidity score and clinical stage, and lack of access to CT, RT, and EG were independent predictors of mortality (Table 1). Conclusions: Females with EC seem to have less access to CT, RT, and EG with worse OS than males. Healthcare policies should focus on increasing access to standard treatments for female patients with EC.[Table: see text]

Impact of gender on treatment and survival of patients with esophageal cancer in the United States

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Background: Esophageal cancer (EC) is historically a male-predominant disease. Current available evidence on the impact of gender on clinical presentation and survival outcomes of EC is limited by small sample size or single institutional series. Methods: Patients with EC (stage I-III) were identified in the National Cancer Data Base (NCDB, 2004-2016). Clinicopathologic and treatment characteristics of male and female patients were compared using Chi-square analysis. Overall survival (OS) was estimated using Kaplan-Meier method and Cox proportional hazards regression. Results: Of 62,893 patients included, male gender was predominant (77.7% vs 22.3%). Adenocarcinoma was the most common subtype (66.7%); however, squamous cell carcinoma was more predominant in females (57.1% vs. 26.5%, p<0.001). Females were significantly older (68.5 vs. 66.1 years; p<0.001) and more likely African American (AA) (14% vs. 8.1%; p<0.001). Females were more likely to present with local disease (stage I, 19.6% vs. 18.2%; p<0.001), while males presented more likely with locoregional disease (LRD, stage II/III, 80.4% vs 81.8%, p<0.001). Females had worse OS compared to males (18.1 vs. 19.7 mo; p=0.001; cI: 23.5 vs. 31.9mo, p<0.001; cII/III: 17.2 vs 18.3mo, p=0.473). White females had worse OS than white males (18.6 vs. 20.4mo, p<0.001), while AA females had better OS (13.5 vs. 12.6mo, p=0.001). Among patients with LRD, females less frequently received chemotherapy (CT, 75.4% vs. 82.9%, p<0.001), radiation therapy (RT, 78.9% vs. 82.6%, p<0.001), and esophagectomy (28% vs. 40.5%, p<0.001). Females who underwent esophagectomy had improved OS over males (40.3 vs. 32.7mo; p<0.001). More specifically, white females who underwent esophagectomy had improved OS over white males (47.6 vs 38mo, p<0.001); however, AA males and females who underwent esophagectomy had similar OS (33.8 vs 32.6mo, p=0.452). Female gender, advanced age, AA race, high comorbidity score and clinical stage, and lack of access to CT, RT, and esophagectomy were independent predictors of mortality (Table). Conclusions: Females with EC seem to have less access to CT, RT and esophagectomy, which is associated with worse OS compared to males. Healthcare policies should be implemented to increase access to standard of care treatment for female patients with EC. [Table: see text]

Does Neoadjuvant Chemotherapy Change the Role of Regional Lymphadenectomy in Pancreatic Cancer Survival?

OBJECTIVES

The objective of this study was to evaluate the role of lymph node (LN) dissection and staging in outcomes of patients with pancreatic adenocarcinoma (PDAC) who underwent neoadjuvant chemotherapy (NAC).

METHODS

National Cancer Database was queried for patients with stages I to III PDAC diagnosed between 2004 and 2014. Overall survival (OS) was derived from Kaplan-Meier methods, and Cox-regression model was used to evaluate associations between the number of LN examined, number of positive nodes, and LN ratio with OS.

RESULTS

A total 35,599 patients were included, 3395 (9%) underwent NAC, 19,865 (56%) received adjuvant chemotherapy (AC), and 12,299 (35%) underwent surgery alone. Cox-regression showed superior OS in NAC compared with AC and surgery alone (26 vs 23 vs 14 months, P < 0.001). Minimum number of LN examined affecting OS was 8 LNs in NAC (23.8 vs 26.6 months, P = 0.029), and 12 LNs in AC group (22 vs 23.1 months, P = 0.028). Lymph node ratio cutoff of greater than 0.2 was associated with decreased OS (19.4 vs 24.4 months, P < 0.001).

CONCLUSIONS

Neoadjuvant chemotherapy is associated with improved survival in PDAC. Lymph node yield remains a significant prognostic factor after NAC, whereas the minimum number of harvested LNs associated with sufficient staging and survival is decreased.

Impact of neoadjuvant radiation on survival in patients with pancreatic cancer undergoing neoadjuvant chemotherapy followed by pancreatectomy

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Background: Pancreatic adenocarcinoma (PDAC) carries a dismal prognosis. Neoadjuvant chemoradiation therapy (NACR) has been introduced to enhance the outcomes of patients with borderline resectable and locally advanced PDAC, however the role of radiation therapy remains largely unknown. Methods: The National Cancer Database (NCDB) was queried for patients with stage I-III PDAC who underwent surgical resection from 2004 to 2014. Patients undergoing NACR were compared to those undergoing neoadjuvant chemotherapy (NAC) alone. The association between clinical characteristics and overall survival (OS) was assessed using the Kaplan-Meier method and multivariable Cox regression model. Results: Of 3,133 patients, 2,351 (75%) patients underwent NACR and 782 (25%), NAC alone. Most patients were Caucasians (84%), treated at academic institutions (67%) and underwent pancreaticoduodenectomy (74%). Median follow-up time was 32 months (IQR, 22-50 months). Median number of lymph nodes examined (LNE) and number of positive nodes (NPN) were significantly decreased in NACR (13 vs. 16, p < 0.001 and 0 vs. 1, p < 0.001, respectively). Rates of margin positivity, median OS and 5-year OS were similar between 2 groups (NACR vs. NAC: 15% vs. 17%, p = 0.545; 25.7 months (95% CI 24.4–26.7) vs. 25.1 months (95% CI: 23.9–27.5), and 20% vs. 22%, p = 0.616, respectively, Figure 1). Subgroup analysis of high-risk features (R1/R2 and N1) also showed no difference in survival outcomes. Neoadjuvant radiation was not an independent predictor associated with OS, whereas advanced age, R1/R2, T3/T4, N1, and poorly differentiated histology were independent negative prognostic factors. Conclusions: NACR is associated with lower rates of lymph node positivity, however this did not translate in survival or margin positivity benefit compared to NAC alone. The role of radiotherapy in PDAC continues to evolve, however no convincing data is currently available to advocate the widespread use of radiotherapy in the neoadjuvant setting. Further evidence with prospective clinical trials is still warranted to confirm these findings.

Utility of radiation after neoadjuvant chemotherapy for surgically resectable esophageal cancer

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Background: Neoadjuvant chemotherapy (NAC) is the gold standard approach for locally advanced esophageal cancer (EC), however the addition of radiation remains largely controversial. We sought to investigate the role of neoadjuvant radiation in resectable EC by comparing outcomes of patients who underwent neoadjuvant chemotherapy with (NACR) or without radiation (NAC) using a large nationwide cohort. Methods: National Cancer Data Base (NCDB) was queried for patients with non-metastatic EC between 2010 and 2014. Kaplan-Meier, log-rank and Cox multivariable regression analysis were performed to calculate overall survival (OS). Logistic regression was used to identify factors associated with 90-day mortality and complete pathological response (pCR). Results: A total of 12,546 EC patients who underwent neoadjuvant therapy were included: the majority were males (84%), Caucasians (90.3%), and had adenocarcinoma (81.1%), cT3 (60.6%) and cN1 (49.1%). 11,269 (89.8%) patients had NACR, whereas 969 (7.7%), NAC alone. pCR rate was 14.1% (19.2%, NACR vs. 6.3%, NAC, p < 0.001). Neoadjuvant radiation was an independent predictor for improved pCR [HR 0.305, 95% CI 0.205-0.454, p < 0.001], however OS was similar in patients undergoing NAC with or without radiation (35.9 vs. 37.6 months, respectively, p = 0.393). This persisted regardless of tumor staging. There was a trend towards worse 90-day mortality after radiation (8.2%, NACR vs. 7.7%, NAC; HR 1.410, 95% CI 0.975-2.038, p = 0.068). In Cox regression, controlling for patient and disease-related factors, neoadjuvant radiation was an independent predictor of worse OS (HR 1.322, 965% CI 1.177-1.485, p < 0.001). Conclusions: This is the largest study comparing NACR versus NAC in resected EC. The addition of radiation to neoadjuvant chemotherapy is associated with improved pathological response rates, however it had deleterious effects in long-term and possibly, short-term survival. Our findings suggest that NAC without radiation may be the optimal neoadjuvant therapy in resectable EC, however further evidence with randomized clinical trials is warranted.