3 years ago

Comparative Effectiveness of Upfront Esophagectomy vs Induction Chemoradiation in Clinical Stage T2N0 Esophageal Cancer: A Decision Analysis

We compared the effectiveness of upfront esophagectomy versus induction chemoradiation followed by esophagectomy for overall survival in patients with clinical T2N0 esophageal cancer. We also assessed the impact of the diagnostic uncertainty of endoscopic ultrasound on the expected benefit of chemoradiation. Methods We created a decision analysis model representing two treatment strategies for cT2N0 esophageal cancer: 1) upfront esophagectomy which may be followed by adjuvant therapy for upstaged patients and 2) induction chemoradiation for all cT2N0 patients followed by esophagectomy. Parameter values within the model were obtained from published data, and median survival for pathologic subgroups was derived from the National Cancer Database. In sensitivity analyses, staging uncertainty of endoscopic ultrasound was introduced by varying the probability of pathological upstaging. Results The baseline model showed comparable median survival for both strategies: 48.3 months for upfront esophagectomy versus 45.9 months for induction chemoradiation and surgery. The sensitivity analysis demonstrated induction chemoradiation was beneficial with probability of upstaging greater than 48.1%, which is within the published range of 32-65% probability of pathologic upstaging after cT2N0 diagnosis. The presence of any of three key variables: size over 3 cm, high grade, or lymphovascular invasion was associated with greater than 48.1% risk of upstaging, thus conferring a survival advantage to induction chemoradiation. Conclusions The optimal treatment strategy for cT2N0 esophageal cancer depends upon the accuracy of endoscopic ultrasound staging. High-risk features that confer increased probability of upstaging can inform clinical decision-making to recommend induction chemoradiation for select cT2N0 patients.

Publisher URL: www.sciencedirect.com/science

DOI: S0022522318300540

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