Endoscopic outcomes in early esophageal cancer

Sachin Wani, MD, from the University of Colorado and Veterans Affairs Medical Dr. Sachin WaniCenter in Denver, Colorado, USA discusses his Original Article “Comparison of endoscopic therapies and surgical resection in patients with early esophageal cancer: a population-based study” from the February issue.

The aims of this study were to use the Surveillance, Epidemiology and End Results (SEER) database to (1) compare mid- (2 years) and long- (5 years) term overall survival and esophageal cancer (EC)-specific mortality in patients with early EC treated with endoscopic eradication therapies (EET) and esophagectomy; (2) compare outcomes (EC-free survival) based on histology (esophageal adenocarcinoms [EAC]) and stage; and (3) evaluate the treatment patterns and independent associations of treatment received with cancer-specific mortality.

The incidence of EC continues to increase faster than almost any other cancer in the Western World and is associated with a dismal 5-year survival rate. Given the high tumor-free survival rates, esophagectomy has been the standard treatment for patients with early EC with which all other therapies are compared. However, esophagectomy for early EC is associated with an overall operative mortality rate of 2% and major morbidity rate as high as 10%, even in high-volume centers and centers with multidisciplinary care. Based on a growing body of literature suggesting favorable outcomes compared with esophagectomy, EET have gained gradual acceptance and are endorsed in society guidelines, especially in the field of Barrett’s esophagus related to neoplasia. Although data suggest that EET are highly effective, studies comparing EET with surgical resection are limited.

Figure 2Figure 2. Proportion of esophageal cancer treated by endoscopic eradication therapy by stage and time.

A total of 2016 patients with early EC undergoing EET (n= 430, 21.3%) and esophagectomy (n= 1586,78.7%) between 1998 and 2009 meeting inclusion criteria were identified. The vast majority of cases were white men, and the overall histological distribution was EAC, 1567 (77.7%); esophageal squamous cell carcinoma (ESCC), 311 (13.3%); and others, 179 (9%). The distribution based on stage of disease was as follows: stage T0, 357 (17.7%); stage T1a, 935 (46.3%); and stage T1b, 724 (36%). EMR was the predominant treatment modality followed by EMR with ablation. Results of this large population-based study demonstrate comparable 2- and 5-year EC-specific survival rates between patients receiving EET and surgical resection. Similar long-term results were noted when analyses were limited to stages T0 and T1a. Cox proportional hazards regression models showed that the HR for EC-free survival in the EET group was not different from that of the esophagectomy group (HR 1.42; 95% CI, 0.9-2.03). Similar results were noted when modeling was limited to stages 0 and 1a (HR 1.18; 95% CI, 0.78-1.8). This study demonstrates comparable 2- and 5-year EC-related survival in patients with EAC.

Our results highlight not only the increasing use of EET in the management of patients with early EC (overall and stage specific), but also the intrinsic differences in the characteristics of patients undergoing EET and esophagectomy. Patients in the EET group were frequently older and more likely to demonstrate well-differentiated tumor histology, whereas patients in the esophagectomy group were more likely to show larger tumors and receive radiation therapy. Age and higher comorbidity is the most likely explanation for poorer overall 5-year survival and higher mortality rates attributed to other non-EC causes in the EET group. Results also showed that the age at diagnosis, exposure to radiation therapy, increasing stage of disease (stages T1a and T1b), and year of diagnosis were all variables associated with increasing mortality rates, whereas tumor histology of EAC was associated with improved survival compared with ESCC. Similar results were noted when modeling was limited to stage T0 and T1a cases.

Find this article on pages 224-232 of the print journal or read the abstract online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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