There is no accepted surveillance strategy following curative oesophageal cancer management, with reinvestigation often relying on symptom development. Lack of a surveillance standard may impact on outcome and survival. We hypothesized that strict surveillance was more likely to detect curable recurrent disease. This study compared the outcome for salvage surgery for recurrent disease, detected on a strict surveillance program, with survival of patients that had undergone immediate surgery following an incomplete response to neoadjuvant chemoradiotherapy. A prospective database of oesophageal carcinoma patients who were treated with curative intent (Surgery alone, Neoadjuvant Chemoradiotherapy (NeoCR) plus surgery, Definitive Chemoradiotherapy or Neoadjuvant Chemoradiotherapy with surveillance by choice), was interrogated for patients with recurrent disease amenable to salvage surgery. Surveillance for all consisted of 3-monthly endoscopy and 6-monthly CT scanning for 3 years, followed by 6-monthly endoscopy and yearly CT scanning to 5 years, and both yearly thereafter. If recurrence was diagnosed patients were restaged and, if suitable, underwent salvage surgery. Their outcome was compared with patients undergoing neoadjuvant chemoradiotherapy and having immediate surgery for an incomplete response. Of 205 patients treated with curative intent, 18 (9%) underwent salvage surgery for locoregional recurrence. They had a median survival of 61.6 months (range 10.32 to 136.08) and a 3-year survival of 50%. This compares to 115 patients who underwent surgery following incomplete response to NeoCR, who had a median survival of 38.3 months (range 2.20 to 254.26) and a 3 year survival of 44%, which was statistically insignificant between the groups (p= 0.975). The overall mean survivals were 57.84 months and 57.9 months respectively. Intensive surveillance identified a cohort of patients (9% of total) with recurrence amenable to salvage surgery and with outcomes non-inferior to immediate surgery following NeoCR. As most were asymptomatic, it is suggested that without surveillance the opportunity for curative intervention would have been lost. Even novel treatments will require detection of recurrence before disease becomes unmanageable. It is suggested that surveillance guidelines be updated to standardize interval endoscopy/imaging, as for other GI malignancies.
The incidence of esophageal cancer is higher in men, with evidence that men present at a more advanced stage. Randomized trials of neoadjuvant treatments have hitherto not stratified for gender, but it is unclear whether the response to neoadjuvant chemoradiotherapy (NeoCR) and outcome is similar for both genders. The aim of this study is to compare presentation, response to treatment and survival of esophageal cancer between men and women. A prospectively maintained database of 205 patients (143 males; 70%) diagnosed with esophageal carcinoma and treated with curative intent (definitive chemoradiotherapy, neo-adjuvant chemoradiotherapy followed by surgery or surveillance, or surgery alone), between 1998 and 2019 at one teaching hospital, was interrogated for impact of gender on response to treatment (complete versus incomplete clinical response) and survival. Of 36 females who had NeoCR, 28 (78%) had a complete clinical response, compared to 52 of 116 males (45%). The complete pathological response rate was 21 of 36 (58.3%) of females compared to 31% of men (P<0.001). Controlling for age, stage at diagnosis, and type of therapy, females survived significantly longer than males [HR 0.72 CI 0.53-0.98 (p=0.038)]. Our results suggest a gender difference in response to chemoradiotherapy, which is reflected in outcome and survival. It is suggested that future randomized trials of neoadjuvant and indeed adjuvant therapy stratify for gender which may impact on management guidelines.
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