NEW YORK (Reuters Health) - Delays in surgery for advanced esophageal cancer, such as those implemented in the first months of the COVID-19 pandemic, result in significantly worse outcomes, a new analysis found.
Delayed surgery did not appear to affect survival for patients with stage I esophageal cancer, however, according to an analysis of data collected in National Cancer Database from 2010-2017, reported in the Journal of the American College of Surgeons by Dr. Simar S. Bajaj of the Massachusetts General Hospital in Boston and colleagues.
Of the 542 patients with stage I cancer, 226 (41.7%) underwent early esophagectomy (i.e., within four weeks after diagnosis) and 316 (58.3%) underwent delayed esophagectomy (12-16 weeks after diagnosis). In an unadjusted analysis, there were no differences in mortality at 30 days (1.3% vs 2.8%, respectively) or 90 days (4% vs 4.7%). Five-year survival rates were also similar (70.3% vs 69.8, p=0.35). No differences were found in a landmark analysis of patients who survived at least 6 months. In a multivariate analysis including T and N stage of tumor, delayed esophagectomy was not associated with a worse survival (HR 1.08, 95% CI 0.74-1.57, p=0.69).
Furthermore, there were no differences in 30- or 90-day mortality between propensity-matched groups with stage I cancer who underwent either early or delayed surgery. Five-year survival rates with early vs delayed surgery in the propensity-match groups were also similar (65.0% vs 65.1%, log-rank p=0.50).
Among the 1,436 patients with stage II/III esophageal cancer who received timely chemoradiation (within four weeks after diagnosis), 1,236 (86.1%) had early esophagectomy (9-17 weeks after diagnosis) and 200 (13.9%) received delayed esophagectomy (21-29 weeks after diagnosis).
In unadjusted analysis, early esophagectomy was associated with lower mortality at 30 days (1.5%, n=19, vs 5.0%, n=10; p=0.001) and 90 days (4.5%, n=55, vs 10.1%, n=20; p=0.001), compared with delayed esophagectomy. Early esophagectomy was also associated with improved five-year survival (48.4% vs 28.6%, log-rank p<0.001).
In a landmark analysis of patients who survived 6 months, early esophagectomy still yielded better five-year survival compared to delayed surgery. In multivariate analysis, delayed esophagectomy had overall worse survival compared to early esophagectomy (HR 1.72 95% CI 1.33-2.21).
In two propensity score matching analyses, early esophagectomy was associated with superior five-year survival (clinical T and N status matching, 41.6% vs 22.9%, p=0.006; pathological T and N status matching, 43.2% vs 21.6% p=0.001).
The authors acknowledge some limitations of their study, including the fact that data on morbidity, cause of death, and cancer-specific, recurrence-free, and disease-free survival data were not available.
Still, they speculate that "deferral of surgery may lead to reduced survival for patients with stage II/III esophageal cancer because of increased risk of disease progression and recurrence."
In an editorial, Dr. Nicholas Contreras of Murray, Utah and Dr. Virginia Litle agree with what they call the "take-home" message of the report: "Stage 1 could wait. Locally and regionally advanced cases could not."
"Timely esophagectomy for locally and regionally advanced cancers is the path to take when traversing an unfamiliar and unpredictable infectious world," they add. "This will likely not be our last pandemic, so let this be a source of guidance for the next one."
SOURCE: https://bit.ly/3wBB4W1 Journal of the American College of Surgeons, online May 12, 2022.
Reuters Health Information © 2022