Association of Guideline-Concordant Care with Superior Survival Outcomes for Clinical T2N0M0 Esophageal Squamous Cell Carcinoma.

Abstract

For patients with clinical T2N0M0 (cT2N0M0) esophageal squamous cell carcinoma (ESCC), upfront esophagectomy is recommended for low-risk tumors (tumor size less than 3 cm, low-grade histology), and neoadjuvant chemoradiation with esophagectomy or chemoradiation alone is recommended for high-risk tumors (tumor size 3 cm or greater, high-grade histology). The objectives of this study were to (1) describe the treatment strategies used for patients with cT2N0M0 ESCC and (2) analyze survival outcomes for patients according to treatment strategy and tumor risk category. We performed a retrospective cohort analysis of patients with cT2N0M0 ESCC in the National Cancer Database from 2006 to 2020 comparing patients by tumor risk categories. We compared characteristics of patients according to treatment strategy using bivariate analyses. We performed multivariable Cox regressions comparing overall survival outcomes of patients according to treatment strategy and tumor risk category. Of the included patients, 145 of 890 (16.3%) with cT2N0M0 ESCC underwent esophagectomy, 176 of 890 (19.8%) underwent neoadjuvant chemoradiation with esophagectomy, and 418 of 890 (47.0%) underwent chemoradiation. Among patients with low-risk cT2N0M0 ESCC, 44 of 222 (19.8%) underwent esophagectomy. Among patients with high-risk cT2N0M0 ESCC, 126 of 668 (18.9%) underwent neoadjuvant chemoradiation with esophagectomy and 332 of 668 (49.7%) underwent chemoradiation therapy. Patients with high-risk tumors undergoing chemoradiation had a 53% higher risk of death than patients with high-risk tumors undergoing neoadjuvant chemoradiation with esophagectomy (adjusted hazard ratio 1.53 [1.15 to 2.05]). Approximately half of patients with cT2N0M0 ESCC received guideline-concordant care. Chemoradiation therapy is overused in patients with high-risk tumors and upfront esophagectomy is underused in patients with low-risk tumors.