Trends in Treatment of T1N0 Esophageal Cancer

Tara R. Semenkovich, MD, MPHS; Jessica L. Hudson, MD, MPHS; Melanie Subramanian, MD; Daniel K. Mullady, MD; Bryan F. Meyers, MD, MPH; Varun Puri, MD, MSCI; Benjamin D. Kozower, MD, MPHY

Disclosures

Annals of Surgery. 2019;270(3):434-443. 

In This Article

Abstract and Introduction

Abstract

Objective: The purpose of this study was to explore nationwide trends in treatment and outcomes of T1N0 esophageal cancer.

Background: Endoscopic treatment has become an accepted option for early-stage esophageal cancer, but nationwide utilization rates and outcomes are unknown.

Methods: T1N0 esophageal cancers were identified in the National Cancer Database from 2004 to 2014. We assessed trends in treatment; compared endoscopic therapy, esophagectomy, chemoradiation, and no treatment; and performed a subgroup analysis of T1a and T1b patients from 2010 to 2014 (AJCC 7).

Results: A total of 12,383 patients with clinical T1N0 esophageal cancer were analyzed. Over a decade, use of endoscopic therapy increased from 12.7% to 33.6%, whereas chemoradiation and esophagectomy decreased, P< 0.01. The rise in endoscopic treatment of T1a disease from 42.7% to 50.6% was accompanied by a decrease in esophagectomies from 21.7% to 12.8% (P < 0.01). For T1b disease, the rise in endoscopic treatment from 16.9% to 25.1% (P = 0.03) was accompanied by decreases in no treatment and chemoradiation, whereas the rate of esophagectomies remained approximately 50%. Unadjusted median survival was longer for patients undergoing resection: esophagectomy, 98.6 months; endoscopic therapy, 77.7 months; chemoradiation, 17.3 months; no treatment, 8.2 months; P < 0.01. Risk-adjusted Cox modeling showed esophagectomy was associated with improved survival [hazard ratio (HR): 0.85], and chemoradiation (HR: 1.79) and no treatment (HR: 3.57) with decreased survival, compared to endoscopic therapy (P < 0.01).

Conclusions: Use of endoscopic therapy for T1 esophageal cancer has increased significantly: for T1a, as an alternative to esophagectomy; and for T1b, as an alternative to no treatment or chemoradiation. Despite upfront risks, long-term survival is highest for patients who can undergo esophagectomy.

Introduction

Endoscopic treatment has become an accepted option for early-stage esophageal cancer. Given the substantial morbidity of esophagectomy, combined with the ease of access to the esophagus via endoscopy and advancing technology for various types of endoscopic therapy,[1] definitive local treatment is appealing. For high-grade dysplasia, endoscopic therapy has been shown to successfully eradicate disease,[2] is cost-effective,[3] and has become the standard of care.[4] For early-stage cancers, evidence showing acceptable outcomes following endoscopic resection has been predominantly demonstrated in single-institution or retrospective database studies comparing the treatment to esophagectomy.[5]

Based on the available data, endoscopic treatment for T1N0 esophageal cancer has become integrated in national guidelines as a possible option, although there is variability in the specific tumors and patients that are eligible. The Society of Thoracic Surgeons guidelines view endoscopic mucosal resection as a useful diagnostic procedure to definitively determine the depth of invasion, and as a possible therapeutic option for superficial tumors without lymphadenopathy.[6] However, the American Society for Gastrointestinal Endoscopy guidelines recommend endoscopic eradication therapy as primary treatment for intramucosal esophageal cancer.[5] The National Comprehensive Cancer Network (NCCN) guidelines state that endoscopic resection with or without ablation is the preferred strategy for pathologic T1a disease, an option for superficial pathologic T1b disease in surgically fit patients, and an option for all pathologic T1b disease in patients who are not surgical candidates.[4] Tenets of treatment generally include appropriate clinical staging demonstrating node-negative localized disease, a low-grade tumor small enough to allow for complete resection with negative margins, and ablation of residual Barrett esophagus.[1]

The purpose of this study was to explore nationwide trends in treatment and outcomes of T1 esophageal cancer over a decade, from 2004 to 2014. We hypothesized that the use of endoscopic therapy increased over the time period of the study and that the percentage of patients receiving an esophagectomy, chemoradiation, and no treatment decreased because of the availability of an alternative, lower-risk treatment option for patients with substantial comorbidities.

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