Treatment modalities for T1N0 esophageal cancers: a comparative analysis of local therapy versus surgical resection

Abstract

Background: To investigate the role of nonsurgical treatment for early-stage esophageal cancer, we compared the outcomes of local therapy to esophagectomy, using a large, national database.

Methods: Five-year cancer-specific and overall survival (OS) of patients, with T1N0M0 squamous cell or adenocarcinoma of the mid or distal esophagus treated with either surgery or local therapy, with ablative and/or excision techniques, in the Surveillance Epidemiology and End Results cancer registry from 1998 to 2008, were compared using the Kaplan-Meier approach, and multivariable and propensity-score adjusted Cox proportional hazard, and competing risk models.

Results: Of 1458 patients with T1N0 esophageal cancer, 1204 (83%) had surgery and 254 (17%) had local therapy only. The use of local therapy increased significantly from 8.1% in 1998 to 24.1% in 2008 (p < 0.001). The 5-year OS after local excisional therapy and surgery was not significantly different (55.5% versus 64.1% respectively, p = 0.07), and 5-year cancer-specific survival (CSS) also did not differ (81.7% versus 75.8%, p = 0.10). However, after propensity-score adjustment, CSS was better for patients who underwent local therapy compared with those who underwent surgery (hazard ratio: 0.46, 95% confidence interval: 0.27-0.77, p = 0.003), whereas OS remained similar.

Conclusion: The use of local therapy for T1N0 esophageal cancers increased significantly from 1998 to 2008. Compared with those treated with esophagectomy, patients treated with local therapy had similar OS but improved CSS, indicating a higher chance of dying from other causes. Further studies are needed to confirm the oncologic efficacy of local therapy when used in patients whose lifespans are not limited by conditions other than esophageal cancer.

Figure 1. Change of utilization of esophagectomy and local therapy from 1998 to 2008

Straight line: esophagectomy. Discontinuous line: local therapy. Multivariable adjusted p for trend < 0.001 (OR per year: 1.18, 95% CI: 1.11–1.25)

Figure 2. 5-year cancer specific and overall survival comparing esophagectomy and local therapy

Number of patients at risk at time 0 (esophagectomy: n=1,204; local therapy: n=254). Log rank test for cancer specific survival: p=0.10, for overall survival: p=0.07.

Figure 3

Figure 3a. Cancer-specific and overall survival comparing esophagectomy and local therapy in T1a tumor subgroups Number of patients at risk at time 0 (esophagectomy: n=302; local therapy: n=119). Log rank test for cancer specific survival: p=0.93, for overall survival: p=0.31. Figure 3b. Cancer-specific and overall survival comparing esophagectomy and local therapy in T1b tumor subgroups Number of patients at risk at time 0 (esophagectomy: n=296; local therapy: n=27). Log rank test for cancer specific survival: p=0.07, for overall survival: p=0.80.

Figure 3

Figure 3a. Cancer-specific and overall survival comparing esophagectomy and local therapy in T1a tumor subgroups Number of patients at risk at time 0 (esophagectomy: n=302; local therapy: n=119). Log rank test for cancer specific survival: p=0.93, for overall survival: p=0.31. Figure 3b. Cancer-specific and overall survival comparing esophagectomy and local therapy in T1b tumor subgroups Number of patients at risk at time 0 (esophagectomy: n=296; local therapy: n=27). Log rank test for cancer specific survival: p=0.07, for overall survival: p=0.80.