Adjuvant Therapy for Node-Positive Esophageal Cancer After Induction and Surgery: A Multisite Study

• Type of Material: Article
• Authors: Tara R. Semenkovich, Washington University; Melanie Subramanian, Washington University; Yan Yan, Washington University; Wayne L. Hofstetter, MD Anderson Cancer Center; Stephen D. Cassivi, Mayo Clinic; Matthew L. Inra, Mayo Clinic; Brendon M. Stiles, Weill Cornell Medicine; Nasser K. Altorki, Weill Cornell Medicine; Andrew C. Chang, Michigan Medicine; Alexander A. Brescia, Michigan Medicine; Gail E. Darling, University of Toronto; Frances Allison, University of Toronto; Stephen R. Broderick, Johns Hopkins University; Eric W. Etchill, Johns Hopkins University; Felix Fernandez, Emory University; Ray K. Chihara, Emory University; Virginia R. Litle, Boston Medical Center; Juan A. Munoz-Largacha, Boston Medical Center; Benjamin D. Kozower, Washington University; Varun Puri, Washington University; Bryan F. Meyers, Washington University
• Language: English
• Date: 2019-09-01
• Publisher: Elsevier Science Inc.
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2019 by The Society of Thoracic Surgeons Published by Elsevier.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.athoracsur.2019.04.099
• Title of Journal or Parent Work: Annals of Thoracic Surgery
• Volume: 108
• Issue: 3
• Start Page: 828
• End Page: 836
• Grant/Funding Information: None declared
• Keywords: Life Sciences & Biomedicine; Respiratory System; Surgery; Neoadjuvant chemoradiation; Cardiac & Cardiovascular Systems; Cardiovascular System & Cardiology; Science & Technology
• Research Categories: Health Sciences, Medicine and Surgery; Health Sciences, Health Care Management; Health Sciences, Oncology

Abstract

Background: The benefit of adjuvant treatment for esophageal cancer patients with positive lymph nodes following induction therapy and surgery is uncertain. This in-depth multicenter study assessed the benefit of adjuvant therapy in this population. Methods: A retrospective cohort study from 9 institutions included patients who: received neoadjuvant treatment, underwent esophagectomy from 2000–2014, and had positive lymph nodes on pathology. Factors associated with administration of adjuvant therapy were assessed using multilevel random-intercept modeling to account for institutional variation in practice. Kaplan-Meier analyses were performed based on adjuvant treatment status. Variables associated with survival were identified using Cox proportional hazards modeling. Results: 1,082 patients were analyzed with node positive cancer following induction therapy and esophagectomy. 209 (19.3%) received adjuvant therapy and 873 (80.7%) did not. Administration of adjuvant treatment varied significantly from 3.2% to 50.0% between sites (p<0.001). Accounting for institution effect, factors associated with administration of adjuvant therapy included clinically positive and negative prognostic characteristics: younger age, higher pathologic stage, pathologic grade, no neoadjuvant radiation, non-smoking status, and absence of postoperative infection. On Kaplan-Meier analysis, patients receiving adjuvant therapy had a longer median survival: 2.6 years vs 2.3 years, p=0.02. Cox modeling identified adjuvant treatment as independently associated with improved survival, with a 24% reduction in mortality (HR=0.76, p=0.005). Conclusions: Adjuvant therapy was associated with improved overall survival. Therefore, consideration should be given to administration of adjuvant therapy to esophageal cancer patients who have persistent node positive disease after induction therapy and esophagectomy, and are able to tolerate additional treatment.