title: Clinical predictors of early cancer-related mortality following neoadjuvant therapy and oesophagectomy.
abstract: OBJECTIVE
  Although oesophagectomy can be curative for patients with oesophageal cancer (OC), it may be associated with high morbidity and decreased quality of life. Identifying risk factors for early systemic progression or death after oesophagectomy may help to guide treatment choices in at-risk patients.
  
  
  METHODS
  Patients undergoing oesophagectomy following neoadjuvant therapy for OC (November 1987 to January 2013) were reviewed, excluding deaths ≤3 months. Univariate predictors of death ≤1 year of operation were explored by logistic regression. Significant predictors (P ≤ 0.10) were included in a multivariate model. A risk factor index was created based on the number of significant risk factors in individual patients.
  
  
  RESULTS
  Of 581 patients, 238 had neoadjuvant chemotherapy or chemotherapy and radiation followed by oesophagectomy. Of these, 15% (n = 36) died ≤1 year following oesophagectomy and 69% of those from documented cancer recurrence. Clinical predictors of death ≤1 year by multivariate analysis included performance status >0 (HR 2.19; CI 1.02-4.69), poor (G3) tumour differentiation (HR 2.67; CI 1.14-6.21) and lack of clinical response (no response or progression versus complete and partial response) to neoadjuvant therapy (HR 2.77; CI 1.07-7.15). For patients with all factors evaluable (n = 167), variables were summed to derive a cumulative risk factor index, 0-3. An increased risk factor index (≥2) was highly associated with increased risk of death ≤1 year postoperatively (HR 4.84; CI 1.93-12.16), as well as with poor overall survival.
  
  
  CONCLUSIONS
  Clinically defined risk factors that predict early mortality following oesophagectomy include performance status, poor tumour differentiation and clinical response. In patients with at least two of these risk factors, 29% will die within 1 year of surgery. These patients should be identified and individual consideration given to less morbid surgical strategies or to alternative treatments.
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA brs9035@med.cornell.edu.
authors.forename: Brendon M
authors.initials: BM
authors.lastname: Stiles
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Gregory G
authors.initials: GG
authors.lastname: Salzler
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Abu
authors.initials: A
authors.lastname: Nasar
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Subroto
authors.initials: S
authors.lastname: Paul
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Paul C
authors.initials: PC
authors.lastname: Lee
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Port
authors.affiliation: Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Nasser K
authors.initials: NK
authors.lastname: Altorki
mesh_terms: D000368:Aged; D003131:Combined Modality Therapy; D004938:Esophageal Neoplasms / Q000188:drug therapy / Q000401:mortality* / Q000601:surgery / Q000628:therapy; D016629:Esophagectomy / Q000401:mortality*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000401:mortality*; D011446:Prospective Studies; D012307:Risk Factors; D016019:Survival Analysis
keywords: Early mortality; Neoadjuvant therapy; Oesophageal cancer; Surgery