Use of multimodality neoadjuvant therapy for esophageal cancer in the United States: assessment of 987 hospitals.

Abstract

Consensus guidelines recommend neoadjuvant therapy in locally advanced esophageal cancer; however, whether this recommendation has been widely adopted is unknown. Therefore, we evaluated the utilization of neoadjuvant therapy in esophageal cancer and its association with outcomes in the United States. From the National Cancer Data Base all patients with middle and lower third clinical stage I-III esophageal cancers who underwent surgical resection were identified (1998-2007). Multivariable regression models were developed to identify predictors of neoadjuvant therapy use and associated outcomes. We identified 8562 patients who underwent surgical resection for esophageal cancer. In nonmetastatic locally advanced tumors, neoadjuvant therapy use increased (stage II 47.9% to 72.5%; stage III 51.0% to 90.1%; P < 0.001). On multivariable analysis, factors associated with the decreased use of neoadjuvant therapy for stage II and III disease were age ≥75 years, Medicare insurance coverage, Charlson score ≥2, stage II (vs. III) disease, and geographic region. Patients with stage II and III disease who underwent neoadjuvant therapy had a lower risk of positive lymph nodes (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.35-0.55) and positive surgical margins (OR 0.51, 95% CI 0.38-0.69). Thirty-day postoperative mortality rates were not significantly affected by neoadjuvant therapy (OR 0.90, 95% CI 0.66-1.24). A pathologic complete response was observed in 10.8% of patients. The only factor that was predictive of pathologic complete response was squamous cell tumor histology (OR 2.14, 95% CI 1.52-3.02). In surgically treated patients, the use of neoadjuvant trimodal therapy has increased in the past decade; however, opportunities exist to improve adherence to national guidelines.