Ann Surg 2022 Jan 27. Epub 2022 Jan 27.
Trinity St. James's Cancer Institute, Trinity College Dublin, and St. James's Hospital, Dublin, Ireland Department of Surgery and Cancer, Imperial College London, 10th Floor, QEQM building, St. Mary's Hospital, London, W21NY, United Kingdom Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Stockholm, Sweden CLINTEC, Karolinska Institutet, Stockholm, Sweden Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
Objective: To determine the impact of surveillance on recurrence pattern, treatment, survival and health-related quality-of-life (HRQL) following curative-intent resection for esophageal cancer.
Summary Background Data: Although therapies for recurrent esophageal cancer may impact survival and HRQL, surveillance protocols after primary curative treatment are varied and inconsistent, reflecting a lack of evidence.
Methods: ENSURE was an international multicenter study of consecutive patients undergoing surgery for esophageal and esophagogastric junction cancers (2009-2015) across 20 centers (NCT03461341). Intensive surveillance (IS) was defined as annual CT for three years postoperatively. The primary outcome measure was overall survival (OS), secondary outcomes included treatment, disease-specific survival, recurrence pattern, and HRQL. Multivariable linear, logistic and Cox proportional hazards regression analyses were performed.
Results: 4,682 patients were studied (72.6% adenocarcinoma, 69.1% neoadjuvant therapy, 45.5% IS). At median follow-up 60 months, 47.5% developed recurrence, oligometastatic in 39%. IS was associated with reduced symptomatic recurrence (OR0.17 [0.12-0.25]) and increased tumor-directed therapy (OR2.09 [1.58-2.77]). After adjusting for confounders, no OS benefit was observed among all patients (HR1.01 [0.89-1.13]), but OS was improved following IS for those who underwent surgery alone (HR0.60 [0.47-0.78]) and those with lower pathological (y)pT stages (Tis-2, HR0.72 [0.58-0.89]). IS was associated with greater anxiety (P = 0.016), but similar overall HRQL.
Conclusions: IS was associated with improved oncologic outcome in select cohorts, specifically patients with early-stage disease at presentation or favorable pathological stage post neoadjuvant therapy. This may inform guideline development, and enhance shared decision-making, at a time when therapeutic options for recurrence are expanding.