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Esophagectomy prolongs esophageal cancer survival
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Patients who underwent esophagectomy after neoadjuvant therapy for esophageal cancer survived significantly longer than those who refused surgery, according to study results presented at the Annual Meeting of The Society of Thoracic Surgeons.
The number of patients who have refused esophagectomy has increased in the past decade; however, the reasons for this trend are not clear, according to Sebron Harrison, MD, of the department of cardiothoracic surgery at Weill Cornell Medicine.
“There has been a lot of emphasis on shared decision-making between patients and physicians as an attempt to empower patients and their loved ones,” Harrison said during a press conference. “However, the flipside to this is that patients can sometimes make a decision that we as physicians do not agree with.
“There are also newer treatment options that do not involve surgery upfront,” Harrison added. “Many times, patients receive neoadjuvant treatment, begin feeling better and do not wish to undergo surgery. However, one of the greatest misunderstandings that we as physicians are afraid of is patient fear of the surgical procedure itself and lack of knowledge about long-term outcomes vs. short-term outcomes.”
Harrison and colleagues sought to determine the proportion of patients with locally advanced esophageal cancer who refused surgery and identify which treatments these patients did receive. They also compared survival outcomes of those who underwent esophagectomy with those who refused surgery.
Researchers used the National Cancer Data Base to analyze data from 18,459 patients with esophageal cancer from 2004 to 2014.
Exclusion criteria included T1N0 stage IV disease, as well as multiple primary and cervical tumors.
Overall, 708 (5.7%) patients were recommended surgery but refused. The database did not include reasons for refusal.
“It is also not specified whether a surgical consultation was obtained or refusal was documented by another treating physician,” Harrison said. “One of the most important limitations was that the timing of refusal was not documented.”
Multivariate analysis identified several predictors for refusal of surgery. They included older age (HR = 1.06; 95% CI, 1.05-1.07), female sex (HR = 1.37; 95% CI, 1.14-1.65), nonwhite race (HR = 2.13; 95% CI, 1.68-2.71), and clinical stage I or II disease (HR = 1.57; 95% CI, 1.35-1.84).
Patients with earlier-stage disease were more likely than those with later-stage disease to refuse surgery.
When researchers assessed the types of treatments patients who refused surgery received, they determined 292 (41%) received definitive chemoradiation, 256 (36%) received sequential chemotherapy/radiation, 58 (8%) received radiation alone or chemotherapy alone, and 102 (15%) received no treatment.
Researchers used propensity matching to compare patients who refused surgery (n=525) with those who underwent surgery (n=525). Results showed those who underwent surgery achieved significantly longer median OS (32.3 months vs. 21.9 months; P < .001).
Predictors of poor OS included increasing age (OR = 1.01; 95% CI, 1-1.01), squamous histology (OR = 0.92; 95% CI, 0.87-0.97) and refusal of surgery (OR = 1.72; 95% CI, 1.54-1.93).
The results offer insights into which patients are more likely to refuse surgery, potentially allowing surgical discussions to be tailored for these patients, Harrison said.
“The greater picture here, and something that does not come across in these database studies, is that the determination of ‘operability’ and those discussions of surgical risks should be managed by thoracic surgeons,” Harrison said.
“[Although] it is understandable that patients may rightfully wish to avoid morbidity and quality of life issues associated with esophagectomy, choice may come at the expense of decreased survival” he added. “Therefore, discussions regarding long-term survival — and not only short-term outcomes — should be part of the decision-making process. We certainly believe that thoracic surgeons should be involved in this discussion.” – by Jennifer Southall
For more information:
Rahouma M, et al. Consequences of refusing surgery for esophageal cancer: A National Cancer Data Base analysis. Presented at: Annual Meeting of The Society of Thoracic Surgeons; Jan. 27-31, 2018; Fort Lauderdale, Fla.
Disclosures: Harrison reports no relevant financial disclosures. Please see the abstract for all other authors’ relevant financial disclosures.
Perspective
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Mark S. Allen, MD
Harrison and colleagues have tried to mine data from the National Cancer Data Base to answer a very important question that is becoming more relevant in day-to-day practice for thoracic surgeons. As surgeons, we are not only interested in the quantity of life for patients, but also their quality of life. It does not do us any good for a patient to live a long life if their quality of life is quite poor. This question of whether a patient should undergo esophagectomy after treatment relates to this.
It is not uncommon for me to see a patient with esophageal cancer. At Mayo Clinic, we initially see these patients in a multidisciplinary fashion. Patients receive chemotherapy and/or radiation, and then they come back to me with no evidence of residual cancer. This is when we have the discussion with the patient about undergoing esophagectomy to increase their cure rate. We never really knew what that exact percentage of increase is.
This study now gives us a number to tell our patients: There is about a 20% increase. This is important because esophagectomy is a substantial operation. It will affect a patient for the rest of his or her life, as it interferes with their eating. I often tell my patients that they will have six smaller meals throughout the day at first instead of three large meals per day because their stomach will be a little bit smaller, and they will lose some of the motility because some of the nerves in the stomach and esophagus are removed during surgery. However, most patients are back to normal meals and eating at 1-year follow-up.
I think this issue of esophagectomy refusal will become more of a problem as new chemotherapy agents become available. We will see more patients who are apparently cured with preoperative treatment, and we will have to decide whether to operate. Of note, the ideal time to operate for the lowest chances of complications is somewhere between 8 and 10 weeks after treatment. I will now reference this study at least a few times per week when talking to my patients about why they should or should not undergo esophagectomy.
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