Early Vs Delayed Surgery Associated With Improved Survival in Stage II/III Esophageal Cancer

Early surgery yielded better survival outcomes in patients with stage II/III esophageal cancer compared with delayed surgery due to the COVID-19 pandemic, according to findings from a study published in the Journal of the American College of Surgeons.¹

The 5-year survival rate was 41.6% (95% CI, 32.1%-50.8%) in the early surgery group compared with 22.9% (95% CI, 14.9%-31.8%; P = .006) in the delayed surgery group for patients with stage II/III disease. However, 5-year survival was comparable between the 2 surgical approaches for patients with stage I disease, at 65.0% (95% CI, 55.2%-73.2%) and 65.1% (95% CI, 55.6%-73.1%; P = .50), respectively.

“When we looked at early vs delayed surgery for patients with stage I cancer, patients in both groups had similar five-year survival rates. However, for patients with stage II or III disease, delayed surgery was associated with worse survival when compared with early surgery,” lead author Simar Singh Bajaj, a student at Harvard Medical School and a investigators in the Department of Surgery at Massachusetts General Hospital, stated in a press release.²

National guidelines during the COVID-19 pandemic recommended that elective surgery for patients with esophageal cancer be delayed by 3 months during times hospital resources were limited. As the impact of these delays are currently unknown, investigators set out to evaluate outcomes in stage I and stage II/III esophageal treated with early and delayed surgery.

Investigators pulled pre-pandemic data from the National Cancer Database from 2010 to 2017. Using these findings, survival data for patients with stage I disease who received early esophagectomy at 0 to 4 weeks after diagnosis were compared with outcomes among those who received delayed surgery at 12 to 16 weeks after diagnosis. Moreover, outcomes were assessed for patients with stage II/III disease who underwent early vs delayed surgery following timely chemoradiotherapy at 9 to 17 weeks or 21 to 29 weeks after diagnosis, respectively.

In the stage I population, a total of 226 patients underwent early surgery and 316 received delayed surgery. The 30-day mortality was comparable between the early (1.3%) and delayed (2.8%) surgery groups (P = .24). Moreover, the 90-day mortality was 4.0% and 4.7% in the early and delayed groups, respectively (P = .69).Investigators also conducted a landmark analysis of patients across both groups who survived for at least 6 months, and no significant differences were reported. Delayed vs early esophagectomy was not associated with worse survival in those with early-stage disease (HR, 1.08; 95% CI, .74-1.57; P = .69).

In the population of patients with stage II/III disease, 1236 patients received early surgery and 200 underwent delayed surgery. The 30-day mortality rate was 1.5% in the early surgery group and 5.0% in the delayed surgery group (P = .001).Moreover, the 90-day mortality in both groups was 4.5% and 10.1%, respectively (P = .001). A landmark analysis that included patients in both cohorts who were alive at 6 months found that 5-year survival was better in the early surgery group vs the delayed surgery group. Moreover, findings from the multivariable analysis indicated the delayed surgery was associated with a worse overall survival (HR, 1.72; 95% CI, 1.33-2.21; P <.001).

“Timely care should always be the priority for patients,” senior author Chi-Fu Jeffrey Yang, MD, a thoracic surgeon at Massachusetts General Hospital in Boston and an assistant professor of surgery at Harvard Medical School, said in a press release.2 “However, there were times during the COVID-19 pandemic when delays to cancer care occurred. This study, using pre-pandemic data, helps us understand the impact of the delay to care for patients with different stages of operable esophageal cancer.”

References

1. Bajaj SS, Shah KM, Potter AL, et al. Early vs delayed operation for esophageal cancer during the COVID-19 pandemic. J Am Col Sur. Published online May 12, 2022. doi:10.1097/XCS.0000000000000248
2. Delays in surgery for advanced esophageal cancer result in significantly worse survival than early surgery. News release. American College of Surgerons. May 12, 2022. Accessed May 13, 2022. https://bit.ly/3sVP2QD