Patient, facility, and surgical factors associated with significant delays to esophagectomy and subsequent poor outcomes: An analysis of 16,486 cases.

Abstract

Delays to definitive surgery in esophageal cancer may be associated with disease progression and worsened survival. The objective of this study was to perform a national assessment for predictors of delay to esophagectomy and to assess for their impact on oncologic and survival outcomes. The National Cancer Database, 2010 to 2020, was queried for patients with locally advanced esophageal adenocarcinoma (stage I-III). Patients were divided into up-front and postneoadjuvant chemoradiation cohorts. The primary outcome was time to surgery. Time to surgery was examined as a continuous and categorical variable, where patients were divided into timely and delayed cohorts (96 days for up-front cohort; 56 days for postneoadjuvant chemoradiation cohort). Of 16,486 patients, 4066 (24.7%) underwent up-front surgery and 12,420 (75.3%) underwent postneoadjuvant chemoradiation surgery. In the up-front surgery group, median [interquartile range] time to surgery was 61 [40-96] days. Risk-adjusted predictors of delay included lack of insurance, lowest quartile of education, biopsy-based staging or surgical staging, and robotic-assisted approach. In the postneoadjuvant chemoradiation, cohort time to surgery was 55 [44-70] days. Risk-adjusted predictors of delay included Hispanic ethnicity, Medicaid or other government-based insurance, lowest quartile of educational status, and robotic approach. In the up-front surgery group, patients who received delayed surgery had increased odds of pathologic upstaging (1.31, 95% CI, 1.06-1.61). In the postneoadjuvant chemoradiation group, patients with surgical delay had increased odds of 90-day mortality (1.27, 95% CI, 1.06-1.51). After risk adjustment for patient, oncologic, facility, and surgical characteristics, there were several predictors of increased time to esophagectomy associated with consequences of upstaging and survival.