title: Induction chemoradiation therapy prior to esophagectomy is associated with superior long-term survival for esophageal cancer.
abstract: The purpose of this study was to examine the role of induction chemoradiation in the treatment of potentially resectable locally advanced (T2-3N0 and T1-3N+) esophageal cancer utilizing a large national database. The National Cancer Data Base (NCDB) was queried for all patients undergoing esophagectomy for clinical T2-3N0 and T1-3N+ esophageal cancer of the mid- or lower esophagus. Patients were stratified by the use of induction chemoradiation therapy versus surgery-first. Trends were assessed with the Cochran-Armitage test. Predictors of receiving induction therapy were evaluated with multivariable logistic regression. A propensity-matched analysis was conducted to compare outcomes between groups, and the Kaplan-Meier method was used to estimate long-term survival. Within the NCDB, 7921 patients were identified, of which 6103 (77.0%) were treated with chemoradiation prior to esophagectomy, while the remaining 1818 (23.0%) were managed with surgery-first. Use of induction therapy increased over time, with an absolute increase of 11.8% from 2003-2011 (P < 0.001). As revealed by the propensity model, induction therapy was associated with higher rates of negative margins and shorter hospital length of stay, but no differences in unplanned readmission and 30-day mortality rates. In unadjusted survival analysis, induction therapy was associated with better long-term survival compared to a strategy of surgery-first, with 5-year survival rates of 37.2% versus 28.6%, P < 0.001. Following propensity score matching analysis, the use of induction therapy maintained a significant survival advantage over surgery-first (5-year survival: 37.9% vs. 28.7%, P < 0.001). Treatment with induction chemoradiation therapy prior to surgical resection is associated with significant improvement in long-term survival, even after adjusting for confounders with a propensity model. Induction therapy should be considered in all medically appropriate patients with resectable cT2-3N0 and cT1-3N+ esophageal cancer, prior to esophagectomy.
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: P J
authors.initials: PJ
authors.lastname: Speicher
authors.affiliation: Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: X
authors.initials: X
authors.lastname: Wang
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: B R
authors.initials: BR
authors.lastname: Englum
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: A M
authors.initials: AM
authors.lastname: Ganapathi
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: B
authors.initials: B
authors.lastname: Yerokun
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: M G
authors.initials: MG
authors.lastname: Hartwig
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: T A
authors.initials: TA
authors.lastname: D'Amico
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.|Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
authors.forename: M F
authors.initials: MF
authors.lastname: Berry
mesh_terms: D000368:Aged; D059186:Chemoradiotherapy, Adjuvant / Q000379:methods / Q000706:statistics & numerical data*; D016208:Databases, Factual; D004938:Esophageal Neoplasms / Q000473:pathology / Q000628:therapy*; D016629:Esophagectomy / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D060828:Induction Chemotherapy / Q000379:methods / Q000706:statistics & numerical data*; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States
keywords: National Cancer Database; esophageal cancer; esophageal surgery; induction therapy; outcome