title: Treatment trends, risk of lymph node metastasis, and outcomes for localized esophageal cancer.
abstract: BACKGROUND
  Endoscopic resection is increasingly used to treat localized, early-stage esophageal cancer. We sought to assess its adoption, characterize the risks of nodal metastases, and define differences in procedural mortality and 5-year survival between endoscopic and surgical resection in the United States.
  
  
  METHODS
  From the National Cancer Data Base, patients with T1a and T1b lesions were identified. Treatment patterns were characterized, and hierarchical regression methods were used to define predictors and evaluate outcomes. All statistical tests were two-sided.
  
  
  RESULTS
  Five thousand three hundred ninety patients were identified and underwent endoscopic (26.5%) or surgical resection (73.5%). Endoscopic resection increased from 19.0% to 53.0% for T1a lesions (P < .001) and from 6.6% to 20.9% for T1b cancers (P < .001). The strongest predictors of endoscopic resection were depth of invasion (T1a vs T1b: odds ratio [OR] = 4.45; 95% confidence interval [CI] = 3.76 to 5.27) and patient age of 75 years or older (vs age less than 55 years: OR = 4.86; 95% CI = 3.60 to 6.57). Among patients undergoing surgery, lymph node metastasis was 5.0% for T1a and 16.6% for T1b lesions. Predictors of nodal metastases included tumor size greater than 2 cm (vs. <2 cm) and intermediate-/high-grade lesions (vs low grade). For example, 0.5% of patients with low-grade T1a lesions less than 2 cm had lymph node involvement. The risk of 30-day mortality was less after endoscopic resection (hazard ratio [HR] = 0.33; 95% CI = 0.19 to 0.58) but greater for conditional 5-year survival (HR = 1.63; 95% CI = 1.07 to 2.47).
  
  
  CONCLUSIONS
  Endoscopic resection has become the most common treatment of T1a esophageal cancer and has increased for T1b cancers. It remains important to balance the risk of nodal metastases and procedural risk when counseling patients regarding their treatment options.
authors.affiliation: Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB). rmerkow@facs.org.
authors.forename: Ryan P
authors.initials: RP
authors.lastname: Merkow
authors.affiliation: Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB).
authors.forename: Karl Y
authors.initials: KY
authors.lastname: Bilimoria
authors.affiliation: Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB).
authors.forename: Rajesh N
authors.initials: RN
authors.lastname: Keswani
authors.affiliation: Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB).
authors.forename: Jeanette
authors.initials: J
authors.lastname: Chung
authors.affiliation: Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB).
authors.forename: Karen L
authors.initials: KL
authors.lastname: Sherman
authors.affiliation: Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB).
authors.forename: Lawrence M
authors.initials: LM
authors.lastname: Knab
authors.affiliation: Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB).
authors.forename: Mitchell C
authors.initials: MC
authors.lastname: Posner
authors.affiliation: Affiliations of authors: Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center (RPM, KYB, JC, KLS, MK, DJB), Surgical Outcomes and Quality Improvement Center, Department of Surgery (RPM, KYB, JC, KLS, MK, DJB), and Department of Medicine, Division of Gastroenterology and Hepatology (RNK), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL (RPM, MCP); Department of Surgery, Jesse Brown VA Medical Center, Chicago, IL (DJB).
authors.forename: David J
authors.initials: DJ
authors.lastname: Bentrem
mesh_terms: D000328:Adult; D000368:Aged; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D004945:Esophagoscopy / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011237:Predictive Value of Tests; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology