Effects of surgical approach and downstaging in esophageal adenocarcinoma patients treated with neoadjuvant chemotherapy: a 2010–2020 National Cancer Database (NCDB) study

TL;DR

This study finds that tumor downstaging after neoadjuvant chemotherapy improves survival in esophageal cancer patients, and minimally invasive surgeries reduce death risk compared to traditional open surgery.

Contribution

The study identifies surgical approach and downstaging as significant predictors of survival in esophageal adenocarcinoma patients treated with neoadjuvant chemotherapy.

Findings

Pathological downstaging is associated with a 31% lower risk of death compared to tumor progression.

Robotic-assisted minimally invasive esophagectomy reduces death risk by 17% compared to open surgery.

Higher clinical T and N stages increase odds of downstaging but decrease odds of complete downstaging.

Abstract

Neoadjuvant Chemoradiation (nCRT) has been shown to improve survival in patients with Esophageal Adenocarcinoma (EAC). The objective of this study is to assess the patient characteristics associated with tumor downstaging in a large national database. Additionally, we evaluated surgical approach and change in clinical versus pathological staging as predictors of patient survival.

Using the 2010–2020 National Cancer Database, we identified 6,400 patients with clinical stage 1B to 4A EAC who received nCRT and underwent esophagectomy. Multivariable logistic models were estimated to evaluate odds of downstaging, and complete downstaging. Multivariable marginal Cox proportional-hazard models were estimated to evaluate all-cause mortality hazard.

3285 (51%) patients downstaged (of which 292 [5% of total] completely downstaged), 2430 (38%) had no change in stage, and 685 (11%) progressed. Generally, higher covariate values such as Clinical T, Clinical N, age, and Charlson-Deyo score were associated with higher odds of downstaging and lower odds of complete downstaging. Downstaging was associated with 31% lower risk of death compared to progression (p < .001) and 17% lower risk of death compared to no change (p < .001). Regarding surgical approach, when compared with open esophagectomy (OE), robotic-assisted minimally invasive esophagectomy (RAMIE) was associated with 17% lower adjusted risk of death (p = .002) while minimally invasive esophagectomy (MIE) was associated with a 10% decrease in adjusted risk of death (p = .009).

In patients with EAC who underwent nCRT, pathological downstaging was associated with increased survival compared to no change or progression. Additionally, RAMIE and MIE were associated with lower risk of death compared to OE.

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