Determinants of Long-term Survival Decades After Esophagectomy for Esophageal Cancer

BACKGROUND Long-term survival in esophagectomy patients with esophageal cancer is low due to tumor-related characteristics, with few reports of modifiable variables influencing outcome. We identified determinants of overall survival, time to recurrence, and disease-free survival in this patient cohort.METHODS Adult patients who underwent esophagectomy for primary esophageal cancer from January 5, 2000, through December 30, 2010, at our institution were identified. Univariate Cox models and multivariable logistic regression analyses were used to identify associations between modifiable and unmodifiable patient and clinical var-iables and outcome of survival for the total cohort and a subgroup with locally advanced disease.RESULTS We identified 870 patients with esophageal cancer who underwent esophagectomy. The median follow-up time was 15 years, and the 15-year overall survival rate was 25.2%, survival free of recurrence was 57.96%, and disease-free survival was 24.21%. Decreased overall survival was associated with the following unmodifiable variables: older age, male sex, active smoking status, history of coronary artery disease, advanced clinical stage, and tumor location. Decreased overall survival was associated with the following modifiable variables: use of neoadjuvant therapy, advanced pathologic stage, resection margin positivity, surgical reintervention, and blood transfusion requirement. The overall survival probability 6 years after esophagectomy was 0.920 (95% CI, 0.895-0.947), and time-to-recurrence probability was 0.988 (95% CI, 0.976-1.000), with a total of 17 recurrences and 201 deaths. CONCLUSIONS Once patients survive 5 years, recurrence is rare. Long-term survival can be achieved in high-volume centers adhering to National Comprehensive Cancer Network guidelines using multidisciplinary care teams that is double what has been previously reported in the literature from national databases.

Automated summary

This study found that long-term survival in patients with esophageal cancer after esophagectomy is low. Unmodifiable variables such as age, sex, smoking history, history of coronary artery disease, and disease stage are associated with decreased overall survival. Modifiable variables such as the use of neoadjuvant therapy, pathologic stage, surgical reintervention, and blood transfusion requirement are also associated with decreased overall survival. The study highlights the importance of high-volume centers using multidisciplinary care teams adhering to national guidelines in improving long-term survival in esophageal cancer patients.