Extended esophagectomy in elderly patients with esophageal cancer: minor effect of age alone in determining the postoperative course and survival

Cancer recurrence and survival among patients who underwent neoadjuvant treatment and surgery for esophageal cancer: A single-institution 10-year experience

BACKGROUND

Standard of care for locally advanced esophageal cancer is neoadjuvant therapy followed by surgical resection. The objective of this study is to explore perioperative factors associated with recurrence and survival among patients with locally advanced esophageal cancer.

METHODS

A retrospective analysis of prospectively collected data on all consecutive minimally invasive Ivor Lewis esophagectomy cases for esophageal cancer performed from September 2013 to September 2023 was performed. Univariable and multivariable Cox proportional hazard regression models were used explore the risk and protective factors associated with recurrence-free and overall survival.

RESULTS

In total, 222 consecutive patients who underwent neoadjuvant chemoradiation followed by minimally invasive Ivor Lewis esophagectomy were included. On univariable analysis, hypertension, Eastern Cooperative Oncologic Group, N stage, number of positive lymph nodes, lymphovascular invasion, cellular differentiation, and positive margins were associated with recurrence. Age, N stage, number of positive lymph nodes, lymphovascular invasion, and cellular differentiation were associated with a worse overall survival. On multivariable analysis, N stage (1.911 [1.295-2.819], P = .009) and worsening cellular differentiation (2.042 [1.036-4.025], P = .039) remained risk factors for recurrence, whereas older age (1.056 [1.013-1.102], P = .011) and cellular differentiation (1.949 [1.004-3.782], P = .049) remained significantly associated with a greater risk of death.

CONCLUSION

Our data suggest that older age and cellular differentiation are strong independent risk factors associated with overall survival. N stage and age are strong independent risk factors associated with both recurrence and survival. These findings may help guide treatment options and shared decision-making among patients with locally advanced esophageal cancer on the basis of their risk and protective factors to maximize recurrence-free and overall survival.

MFI-11 in Chinese elderly esophageal cancer patients with postoperative adverse outcomes

BACKGROUND

Frailty becomes more pronounced with advancing age, tightly intertwined with adverse clinical outcomes. Across diverse medical disciplines, frailty is now universally recognized as not only a risk factor but also a predictive indicator for unfavorable clinical prognosis.

METHODS

This study was a retrospective cohort study that included clinical data from patients (aged ≥ 65 years) with esophageal cancer treated surgically at the First Affiliated Hospital of Anhui Medical University in 2021. For each patient, we calculated their 11-index modified frailty index(mFI-11) scores and categorized the patients into a frailty group (mFI-11hign) and a non-frailty group (mFI-11low) based on the optimal grouping cutoff value of 0.27 from a previous study. The primary study index was the incidence of postoperative pulmonary infection, arrhythmia, anastomotic fistula, chylothorax, and electrolyte disturbance complications. Secondary study indicators included postoperative ICU stay, total hospitalization time, readmission rate within 30 days of discharge, and mortality within 30 days after surgery. We performed univariate and multivariate analyses to assess the association between mFI-11 and adverse outcomes as well as postoperative complications.

RESULTS

Five hundred and fifteen patients were included, including 64.9% (334/515) in the non-frailty group and 35.1% (181/515) in the frailty group. Comparing postoperative complication rates between the two groups revealed lower incidences of postoperative anastomotic fistula (21.5% vs. 4.5%), chylothorax (16.0% vs. 2.1%), cardiac arrhythmia (61.9% vs. 9.9%), pulmonary infections (85.1% vs. 26.6%), and electrolyte disturbance (84.5% vs. 15.0%) in patients of the non-frailty group was lower than that in the frailty group (p < 0.05). mFI-11 showed better prognostic results in predicting postoperative complications. anastomotic fistula (area under the ROC curve AUROC = 0.707), chylothorax (area under the ROC curve AUROC = 0.744), pulmonary infection (area under the ROC curve AUROC = 0.767), arrhythmia (area under the ROC curve AUROC = 0.793), electrolyte disturbance (area under the ROC curve AUROC = 0.832), and admission to ICU (area under the ROC curve AUROC = 0.700).

CONCLUSION

Preoperative frail elderly patients with esophageal cancer have a high rate of postoperative complications. mFI-11 can be used as an objective indicator for identifying elderly patients at risk for esophageal cancer.

Two distinct age-prognosis patterns in patients with esophageal cancer undergoing surgical and radiotherapy treatments: a combined analysis of 3JECROG and SEER databases

Background

Age is a known prognostic factor for various cancers. However, few studies explored the association between age and prognosis of esophageal cancer (EC) comprehensively, especially from a nonlinear perspective.

Design

Retrospective cohort study.

Objectives

Our study aims to explore the possible nonlinear associations between age and prognosis in EC patients receiving curative surgery and radiotherapy, respectively.

Methods

Cox regression models with restricted cubic splines were used to model the possible nonlinear relationship between age and prognosis in surgical and radiotherapy groups, respectively. Surveillance, Epidemiology, and End Results database was used to validate the age-prognosis patterns found in Jing-Jin-Ji Esophageal and Esophagogastric Cancer Radiotherapy Oncology Group database. Age-prognosis patterns were further validated by survival comparisons between different age subgroups and in subsequent sensitivity and subgroup analyses. Primary endpoint is overall survival. Secondary endpoints are cancer-specific survival and progression-free survival.

Results

A total of 56,457 patients from two large cancer databases were included. Patients receiving surgery and radiotherapy showed two distinct nonlinear age-prognosis patterns. Age showed a U-/J-shaped association with prognosis in the radiotherapy group, with a nadir at approximately 65- to 70-years-old. As for surgical cohort, relative risk for all-cause mortality and cancer-specific mortality increased with age with p for nonlinearity <0.05. The above age-prognosis relationships were validated by sensitivity, subgroup, and comparative survival analyses. Youngest and middle-aged patients showed better survival results compared to that of other age subgroups in surgical and radiotherapy cohorts, respectively [Radiotherapy, youngest/middle: hazard ratio (HR) = 1.06, 95% confidence interval (CI): 1.02-1.10, p = 0.001; Radiotherapy, oldest/middle: HR = 1.21, 95% CI: 1.18-1.24, p < 0.001; Surgical, middle/youngest: HR = 1.19, 95% CI: 1.14-1.25, p < 0.001; surgical, oldest/youngest: HR = 1.85, 95% CI: 1.75-1.97, p < 0.001].

Conclusion

Patients receiving surgery and radiotherapy showed two distinct age-prognosis patterns. Younger and middle-aged patients were associated with better survival in surgical and radiotherapy groups, respectively. Additional studies are warranted to explore the underlying mechanisms and clinical implications of this phenomenon.

Textbook outcomes for oesophagectomy: A valid composite measure assessment tool for surgical performance in a specialist unit

INTRODUCTION

In 2017 the Dutch Upper Gastrointestinal Cancer Audit Group proposed a ten-item composite measure for a 'textbook outcome' (TBO) following oesophago-gastric resection. Studies have shown associations between TBO and improved conditional and overall survival. The aim of this study was to evaluate the use of TBO to assess the outcomes from a single specialist unit in a country, with low incidence of disease, allowing comparisons with international specialist centres.

MATERIALS AND METHODS

Retrospective analysis of prospectively collected oesophageal cancer surgery data at a single centre, in Australia, between 2013 and 2018. Multivariable logistical regression assessed association between baseline factors and TBO. Post-operative complications were analysed in two separate groups as Clavien-Dindo ≥2 (CD ≥ 2) and Clavien-Dindo ≥3 (CD ≥ 3). Cox-proportional hazards regression analysis determined the association between TBO and survival.

RESULTS

246 patients were analysed, with 50.8% (n = 125) achieving a TBO when complications were defined as CD ≥ 2 and 58.9% (n = 145) when using CD ≥ 3. Patients aged ≥75, and those with a pre-operative respiratory co-morbidity were less likely to achieve a TBO. Overall survival was not influenced by TBO when complications were defined as CD ≥ 2, however it was higher when a TBO was achieved, and complications were defined as CD ≥ 3 (HR 0.54, 95% CI, 0.35 to 0.84, P = 0.007).

CONCLUSION

TBO is a multi-parameter metric that allowed benchmarking of the quality of oesophageal cancer surgery in our unit, providing favourable outcomes compared with other published data. There was an association between TBO and improved overall survival when the definition of severe complications was CD ≥ 3.

Real-world management and outcomes of older patients with locally advanced esophageal squamous cell carcinoma: a multicenter retrospective study

Background

Neoadjuvant chemotherapy (NAC) followed by surgery is the standard treatment for locally advanced esophageal squamous cell carcinoma (ESCC). Chemoradiotherapy (CRT) is an alternative treatment approach. However, both treatments are associated with toxicity, and the optimal treatment for older patients with ESCC is unknown. This study aimed to evaluate the treatment strategies and prognosis of older patients with locally advanced ESCC in a real-world setting.

Methods

We retrospectively evaluated 381 older patients (≥ 65 years) with locally advanced ESCC (stage IB/II/III, excluding T4) who received anticancer therapy at 22 medical centers in Japan. Based on age, performance status (PS), and organ function, the patients were classified into two groups: clinical trial eligible and ineligible groups. Patients aged ≤ 75 years with adequate organ function and a PS of 0–1 were categorized into the eligible group. We compared the treatments and prognoses between the two groups.

Results

The ineligible group had significantly shorter overall survival (OS) than the eligible group (hazard ratio [HR] for death, 1.65; 95% confidence interval [CI], 1.22–2.25; P = 0.001). The proportion of patients receiving NAC followed by surgery was significantly higher in the eligible group than in the ineligible group (P = 1.07 × 10–11), whereas the proportion of patients receiving CRT was higher in the ineligible group than in the eligible group (P = 3.09 × 10–3). Patients receiving NAC followed by surgery in the ineligible group had comparable OS to those receiving the same treatment in the eligible group (HR, 1.02; 95% CI, 0.57–1.82; P = 0.939). In contrast, patients receiving CRT in the ineligible group had significantly shorter OS than those receiving CRT in the eligible group (HR, 1.85; 95% CI, 1.02–3.37; P = 0.044). In the ineligible group, patients receiving radiation alone had comparable OS to those receiving CRT (HR, 1.13; 95% CI, 0.58–2.22; P = 0.717).

Conclusions

NAC followed by surgery is justified for select older patients who can tolerate radical treatment, even if they are old or vulnerable to enrollment in clinical trials. CRT did not provide survival benefits over radiation alone in patients ineligible for clinical trials, suggesting the need to develop less-toxic CRT.

Risk stratification of postoperative cardiopulmonary toxicity after trimodality therapy for esophageal cancer

Purpose/objective

Postoperative toxicity for esophageal cancer impacts patient quality of life and potentially overall survival (OS). We studied whether patient and toxicity parameters post-chemoradiation therapy predict for post-surgical cardiopulmonary total toxicity burden (CPTTB) and whether CPTTB was associated with short and long-term outcomes.

Materials/methods

Patients had biopsy-proven esophageal cancer treated with neoadjuvant chemoradiation and esophagectomy. CPTTB was derived from total perioperative toxicity burden (Lin et al. JCO 2020). To develop a CPTTB risk score predictive for major CPTTB, recursive partitioning analysis was used.

Results

From 3 institutions, 571 patients were included. Patients were treated with 3D (37%), IMRT (44%), and proton therapy (19%). 61 patients had major CPTTB (score ≥ 70). Increasing CPTTB was predictive of decreased OS (p<0.001), lengthier post-esophagectomy length of stay (LOS, p<0.001), and death or readmission within 60 days of surgery (DR60, p<0.001). Major CPTTB was also predictive of decreased OS (hazard ratio = 1.70, 95% confidence interval: 1.17-2.47, p=0.005). The RPA-based risk score included: age ≥ 65, grade ≥ 2 nausea or esophagitis attributed to chemoradiation, and grade ≥ 3 hematologic toxicity attributed to chemoradiation. Patients treated with 3D radiotherapy had inferior OS (p=0.010) and increased major CPTTB (18.5% vs. 6.1%, p<0.001).

Conclusion

CPTTB predicts for OS, LOS, and DR60. Patients with 3D radiotherapy or age ≥ 65 years and chemoradiation toxicity are at highest risk for major CPTTB, predicting for higher short and long-term morbidity and mortality. Strategies to optimize medical management and reduce toxicity from chemoradiation should be strongly considered.

Outcomes of elderly patients following thoracoscopic esophagectomy for esophageal cancer

PURPOSE

Thoracoscopic esophagectomy (TE) is widely used for esophageal cancer treatment. However, the short- and long-term outcomes of TE in older patients remain unknown. Thus, we investigated those outcomes as well as the effectivity of TE in this patient cohort.

METHODS

A total of 228 consecutive patients who underwent TE for esophageal cancer from 2002 to 2015 were included in the study and categorized into the elderly (≥ 75 years) and non-elderly (< 75 years) groups. The background was adjusted by propensity score matching. The short- and long-term outcomes were then compared between the two groups.

RESULTS

There was no difference in the short-term outcomes between the two groups. The elderly group had significantly lower overall survival (OS) and relapse-free survival (RFS) than the non-elderly group. When pulmonary complications occurred, the OS and RFS were significantly decreased in the elderly group but not in the non-elderly group. Without pulmonary complications, the OS and RFS in the elderly group did not differ from those in the non-elderly group. The multivariate analysis showed that pulmonary complications were independent poor prognostic factors for OS and RFS in the elderly group but not in the non-elderly group.

CONCLUSION

TE is safe and feasible for older patients. However, the OS and RFS of the elderly group were significantly worse than those of the non-elderly group, especially when pulmonary complications occurred. Therefore, perioperative management to prevent pulmonary complications is essential to improve the long-term outcomes of older patients receiving TE.

Impact of Age on the Treatment and Survival in Esophagogastric Cancer

BACKGROUND

The age-specific risks of mortality for patients with esophagogastric cancer and their probability of surgical treatment are not well-known.

METHODS

This population-based, nationwide cohort study included all patients with esophageal or gastric (esophagogastric) cancer in Sweden between 1990 and 2013, with follow-up evaluation throughout 2018. Age at diagnosis (exposure) was categorized into nine 5-year groups. The main outcome was 5-year all-cause mortality. The secondary outcomes were 90-day all-cause mortality, 5-year disease-specific mortality, 5-year disease-specific mortality excluding 90-day all-cause mortality, and non-operation. For mortality outcomes, Cox regression provided hazard ratios (HRs) with 95% confidence intervals (95% CIs) adjusted for confounders. For non-operation, logistic regression provided odds ratios (ORs) with 95% CIs.

RESULTS

Among 28,725 patients, 11,207 (39.0%) underwent surgery. For those who underwent surgery, the HRs of 5-year all-cause mortality were stable before the ages of 65 to 69 years. After that, it gradually increased for patients 65 to 69 years old (HR, 1.13; 95% CI, 1.01-1.26), patients 75 to 79 years old (HR, 1.29; 95% CI, 1.56-1.44), and patients older than 85 years (HR, 1.84; 95% CI, 1.60-2.11) compared with those younger than 50 years. Analyses of age as a continuous variable, other mortality outcomes and stratification by comorbidity and tumor type showed similar results. The odds of non-operation increased for patients 75 to 79 years old (OR, 2.09 [95% CI, 1.84-2.94] for patients 80 to 84 years old and OR, 5.00 [95% CI, 4.31-5.78] for patients ≥85 years old or older), compared with those younger than 50 years.

CONCLUSION

Older age, starting from 65 years, is associated with worse survival after surgery for esophagogastric cancer, and from 75 years with lower odds of surgical treatment.

Esophageal cancer: Outcome and potential benefit of esophagectomy in elderly patients

Background

This analysis evaluated the morbimortality and the potential benefit of esophagectomy for cancer in elderly patients.

Methods

Patients who underwent esophagectomy for EC were divided into elderly (≥70 years) and nonelderly (<70 years) groups. The groups were compared regarding patient and tumor characteristics, postoperative morbimortality, and disease‐free, overall and cancer‐specific survival.

Results

Sixty‐one patients were classified into elderly, and 187 into nonelderly groups. The elderly were characterized by a higher rate of WHO score (p < 0.0001), higher cardiac (p < 0.004) and renal (p < 0.023) comorbidities.

The rate of neoadjuvant therapy and especially of neoadjuvant CRT was significantly lower in elderly patients (p < 0.018 and p < 0.007). Operative morbidity was also higher in this group (p < 0.024).

The 30‐ and 90‐day mortality was 8.2 and 11.5%, respectively in elderly patients and 0.5 and 3.2% in nonelderly patients (p < 0.004 and p < 0.012). This 90‐day mortality decreased when specific surgery‐related deaths were taken into consideration. OS and DFS were significantly better in the nonelderly group (p < 0.003 and p < 0.005) while no difference was observed for cancer‐specific survival (CSS).

Conclusion

No difference in CSS was observed. Although elderly patients with EC had higher postoperative morbimortality, the age should not be a criterion whether to perform, or not to perform, esophagectomy. This decision must be based on the balance between the patient's general condition and aggressive disease.

Perioperative Esophagectomy Outcomes in Older Esophageal Cancer Patients in Two Different Time Eras

To investigate perioperative outcomes of esophagectomies by age groups. Retrospective analysis of esophageal cancer patients undergoing esophagectomy from 2005 to 2020 at a single academic institution. Baseline characteristics and outcomes were analyzed by 3 age groups: <70, 70-79, and ≥80 years-old. Sub-analysis was done for 2 time periods: 2005-2012 and 2013-2020. Of 1135 patients, 789 patients were <70, 294 were 70-79, and 52 were ≥80 years-old. Tumor characteristics, and operative technique were similar, except positive longitudinal margins rates (all <3%) (P = 0.008). Older adults experienced increased complications (53.6% vs 69.7% vs 65.4% respectively; P < 0.001) attributable to grade II complications (41.4% vs 62.2% vs 63.5% respectively; P < 0.001). Hospital length of stay (LOS) and rehabilitation requirements were higher in older adults (both P < 0.05). 30-day readmissions, reoperation, and 30-day mortality rates (all <2%) showed no association with age group. Overall complications, LOS, discharge disposition and re-operative rates improved from 2005 to 2012 to 2013-2020 for all (P < 0.05). Increasing age was an independent risk factor for cardiovascular complications (OR 1.7, 95% CI 1.23-2.46 for ages 70-79 and OR 2.7, 95% CI 1.37-5.10 for ages ≥80 ), inpatient rehabilitation (OR 3.3, 95% CI 2.26-5.05 for ages 70-79 and OR 12.1 95% CI 5.83-25.04 for ages ≥80), and prolonged LOS (OR 1.64 95% CI 1.16-2.31 for ages 70-79 and OR 3.6 95% CI 1.71-7.67 for ≥80. After adjusting for time period, older age remained associated with complications (P < 0.05). Highly selected older adults at a large volume esophagectomy center can undergoesophagectomy with increased minor complication and rehabilitation needs.

Esophageal Cancer in Elderly Patients, Current Treatment Options and Outcomes; A Systematic Review and Pooled Analysis

Simple Summary

Any given treatment may provide improve survival for elderly patients with oesophageal cancer compared to best supportive care. Although surgery may be related to a higher rate of complications in these patients, it also offers the best chance for survival, especially when combined with perioperative chemo-or chemoradiation. Definitive chemoradiation remains also a valid and widely used curative approach in this population. Quality of life after oesophageal cancer treatment does not seem to be particularly compromised in elderly patients, although the risk of loss of autonomy after the disease is higher. Based on the available data, excluding a priori elderly patients from curative treatment based on age alone cannot be supported. A thorough general health status and geriatric assessment is necessary to offer the optimal treatment, tailored to the individual patient.

Abstract

Esophageal cancer, despite its tendency to increase among younger patients, remains a disease of the elderly, with the peak incidence between 70–79 years. In spite of that, elderly patients are still excluded from major clinical trials and they are frequently offered suboptimal treatment even for curable stages of the disease. In this review, a clear survival benefit is demonstrated for elderly patients treated with neoadjuvant treatment, surgery, and even definitive chemoradiation compared to palliative or no treatment. Surgery in elderly patients is often associated with higher morbidity and mortality compared to younger patients and may put older frail patients at increased risk of autonomy loss. Definitive chemoradiation is the predominant modality offered to elderly patients, with very promising results especially for squamous cell cancer, although higher rates of acute toxicity might be encountered. Based on the all the above, and although the best available evidence comes from retrospective studies, it is not justified to refrain from curative treatment for elderly patients based on their age alone. Thorough assessment and an adapted treatment plan as well as inclusion of elderly patients in ongoing clinical trials will allow better understanding and management of esophageal cancer in this heterogeneous and often frail population.

Influences of the Charlson Comorbidity Index and Nutrition Status on Prognosis After Esophageal Cancer Surgery

BACKGROUND

The Charlson Comorbidity Index (CCI), an indicator that objectively quantifies comorbidities, reduces nutritional status; however, the impact of the CCI on the postoperative nutrition indexes of patients with esophageal cancer remains unclear.

METHODS

In total, 336 patients with esophageal cancer who underwent surgery between January 2011 and April 2017 were included in this study. We investigated the relationship between the CCI and postoperative nutrition indexes.

RESULTS

Patients were divided into two groups: CCI ≤1 (low CCI group) and CCI ≥2 (high CCI group). A high CCI was significantly associated with shortened overall survival (OS; 3-year OS rate of 77.9% in the low CCI group versus 59.7% in the high CCI group; p = 0.008). Nutritional indexes, such as the Prognostic Nutritional Index (PNI), at 1 month after esophagectomy were significantly lower in the high CCI group than in the low CCI group (p = 0.031); however, the PNI at 6 months after surgery was similar between the high and low CCI groups. Multivariate analysis identified high CCI as an independent risk factor associated with PNI <45 in esophageal cancer patients at 1 month after esophagectomy (p = 0.047).

CONCLUSION

This study showed that CCI ≥2 was significantly associated with poor PNI at 1 month after surgery for esophageal cancer, indicating that it is necessary to administer effective nutritional interventions for patients with postoperative malnutrition, especially those with multiple comorbidities.

Perioperative mortality of head and neck cancers

Background

Head and neck cancers are aggressive cancers, most clinical studies focused on the prognosis of patients with head and neck cancer. However, perioperative mortality was rarely mentioned.

Methods

A retrospective analysis was performed using all head and neck cancer patients admitting in the Department of Oral and Maxillofacial Surgery of the Second Xiangya Hospital, Central South University from January 2010 to December 2019. The analysis of overall survival and progression-free survival were performed using the Kaplan–Meier method, and cross tabulation with chi-squared testing was applied to analyze the difference in parameters between groups.

Results

From January 2010 to December 2019, a total of 6576 patients with head and neck cancers were admitted to our department and 7 died in the hospital, all of whom were middle-aged and elderly patients including 6 males and 1 female. The perioperative mortality rate (POMR) was about 1‰. The causes of death included acute heart failure, rupture of large blood vessels in the neck, hypoxic ischemic encephalopathy due to asphyxia, respiratory failure and cardiopulmonary arrest.

Conclusion

Preoperative radiotherapy, previous chemotherapy, hypertension, diabetes, advanced clinical stage and postoperative infection are risk factors for perioperative mortality of head and neck cancer.

Outcomes of curative esophageal cancer surgery in elderly: A meta-analysis

BACKGROUND

An increasing number of older patients is undergoing curative, surgical treatment of esophageal cancer. Previous meta-analyses have shown that older patients suffered from more postoperative morbidity and mortality compared to younger patients, which may lead to patient selection based on age. However, only studies including patients that underwent open esophagectomy were included. Therefore, it remains unknown whether there is an association between age and outcome in patients undergoing minimally invasive esophagectomy.

AIM

To perform a systematic review on age and postoperative outcome in esophageal cancer patients undergoing esophagectomy.

METHODS

Studies comparing older with younger patients with primary esophageal cancer undergoing curative esophagectomy were included. Meta-analysis of studies using a 75-year age threshold are presented in the manuscript, studies using other age thresholds in the Supplementary material. MEDLINE, Embase and the Cochrane Library were searched for articles published between 1995 and 2020. Risk of bias was assessed with the Newcastle-Ottawa Scale. Primary outcomes were anastomotic leak, pulmonary and cardiac complications, delirium, 30- and 90-d, and in-hospital mortality. Secondary outcomes included pneumonia and 5-year overall survival.

RESULTS

Seven studies (4847 patients) using an age threshold of 75 years were included for meta-analysis with 755 older and 4092 younger patients. Older patients (9.05%) had higher rates of 90-d mortality compared with younger patients (3.92%), (confidence interval = 1.10-5.56). In addition, older patients (9.45%) had higher rates of in-hospital mortality compared with younger patients (3.68%), (confidence interval = 1.01-5.91). In the subgroup of 2 studies with minimally invasive esophagectomy, older and younger patients had comparable 30-d, 90-d and in-hospital mortality rates.

CONCLUSION

Older patients undergoing curative esophagectomy for esophageal cancer have a higher postoperative mortality risk. Minimally invasive esophagectomy may be important for minimizing mortality in older patients.

Does age affect oesophagectomy survival: a cohort study

BACKGROUND

Curative oesophagectomy for oesophageal cancer is associated with considerable potential mortality. Surgeons are increasingly treating older patients presenting with oesophageal cancer as the population ages. The question remains as to the survival in an older population group, many of whom are not fit for combined multimodal therapy. This study aimed to assess the effect of age on overall survival and disease-free survival in patients undergoing curative oesophagectomy for cancer.

METHODS

Patient data were analysed from a prospectively maintained database. Demographic, surgical and survival outcomes were compared between groups according to age less than 75 years or 75 and older.

RESULTS

Oesophagectomy was performed in 351 patients between 1990 and 2019 (283 patients <75 years, 68 patients ≥75 years). There was a higher rate of neoadjuvant chemotherapy in the younger group (37.7% versus 7.4%; P < 0.001). The 30-day mortality between younger and older groups was similar (2.5% and 2.9%; P = 0.827). There was no statistical difference in 5-year survival rates (50.3% versus 38.6%; P = 0.082) or median survival (22.6 versus 19.3 months; P = 0.053) between groups. There was no statistical difference in 5-year disease-free survival (45.1% and 35.7%; P = 0.180).

CONCLUSION

Overall survival, disease-free survival and 30-day mortality rates in patients aged 75 years and older were not statistically different to their younger counterparts. On the basis of these results, older patients should not be precluded from consideration of potentially curative oesophagectomy on age alone, providing surgery may be performed at reasonable risk.

Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer

INTRODUCTION

Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer.

METHODS

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966).

RESULTS

One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001).

CONCLUSION

Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment.

Impact of Age on Surgical Outcomes for Locally Advanced Esophageal Cancer

BACKGROUND

Older patients are often considered high-risk surgical candidates for locally advanced esophageal cancer, and the benefit of surgery in this population is unclear. This national analysis examines the effect of age on esophagectomy outcomes and compares surgery versus chemoradiation in older patients.

METHODS

The National Cancer Database was used to identify patients with clinical stage II to III esophageal adenocarcinoma undergoing surgery or definitive chemoradiation between 2004 and 2015. Restricted cubic splines were used to examine the relationship between age and survival after esophagectomy, and maximally selected rank statistics were used to identify an age at which survival worsened. We used Cox proportional hazard models including an interaction term between age and treatment to compare overall survival, as well as survival of patients receiving esophagectomy versus definitive chemoradiation.

RESULTS

Of 17,495 patients, 11,680 underwent esophagectomy and 5815 received chemoradiation. Survival after esophagectomy worsened with increasing age and decreased considerably after age 73 (hazard ratio = 1.05, 95% confidence interval, 1.04-1.06, per increasing year after 73 versus hazard ratio = 1.01, 95% confidence interval, 1.00-1.01, per increasing year to 73; both P < .001). Chemoradiation was increasingly used over surgery as age increased. The interaction between age and treatment was significant, and a graph of this interaction demonstrated a survival benefit for surgery over chemoradiation at most ages, including octogenarians.

CONCLUSIONS

Survival worsens with age after esophagectomy for locally advanced esophageal cancer. However, esophagectomy is associated with improved survival compared with definitive chemoradiation at most ages, including octogenarians. Esophagectomy may be considered over chemoradiation for patients who can tolerate surgery regardless of age.

Patient Age and Survival After Surgery for Esophageal Cancer

Background

Esophagectomy for esophageal cancer is associated with a substantial risk of life-threatening complications and a limited long-term survival. This study aimed to clarify the controversial questions of how age influences short-term and long-term survival.

Methods

This population-based cohort study included almost all patients who underwent curatively intended esophagectomy for esophageal cancer in Sweden in 1987–2010, with follow-up through 2016. The exposure was age, analyzed both as a continuous and categorical variable. The probability of mortality was computed using a novel flexible parametric model approach. The reported probabilities are proper measures of the risk of dying, and the related odds ratios (OR) are therefore more suitable measures of association than hazard ratios. The outcomes were 90-day all-cause mortality, 5-year all-cause mortality, and 5-year disease-specific mortality. A novel flexible parametric model was used to derive the instantaneous probability of dying and the related OR along with 95% confidence intervals (CIs), adjusted for sex, education, comorbidity, tumor histology, pathological tumor stage, and resection margin status.

Results

Among 1737 included patients, the median age was 65.6 years. When analyzed as a continuous variable, older age was associated with slightly higher odds of 90-day all-cause mortality (OR 1.05, 95% CI 1.02–1.07), 5-year all-cause mortality (OR 1.02, 95% CI 1.01–1.03), and 5-year disease-specific mortality (OR 1.01, 95% CI 1.01–1.02). Compared with patients aged < 70 years, those aged 70–74 years had no increased risk of any mortality outcome, while patients aged ≥ 75 years had higher odds of 90-day mortality (OR 2.85, 95% CI 1.68–4.84), 5-year all-cause mortality (OR 1.56, 95% CI 1.27–1.92), and 5-year disease-specific mortality (OR 1.38, 95% CI 1.09–1.76).

Conclusions

Patient age 75 years or older at esophagectomy for esophageal cancer appears to be an independent risk factor for higher short-term mortality and lower long-term survival.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-08653-w) contains supplementary material, which is available to authorized users.

Clinical outcomes of oesophagectomy in elderly versus relatively younger patients: a meta-analysis

OBJECTIVES

The surgical efficacy of oesophagectomy for elderly patients (>80 years old) is still unclear. The aim of this meta-analysis was to compare the clinical outcomes of oesophagectomy between elderly and relatively younger patients.

METHODS

PubMed, EMBASE and the Cochrane Library were searched for relevant studies comparing the clinical outcomes of oesophagectomy for elderly and relatively younger patients. Odds ratios were extracted to obtain pooled estimates of the perioperative effect, and hazard ratios were extracted to compare survival outcomes between the 2 cohorts.

RESULTS

Nine studies involving 4946 patients were included in this meta-analysis. For patients older than 80 years of age, in-hospital mortality [odds ratio (OR) 2.00, 95% confidence interval (CI) 1.28-3.13; P = 0.002] and the incidence rates of cardiac (OR 1.55, 95% CI 1.10-2.20; P = 0.01) and pulmonary (OR 1.57, 95% CI 1.11-2.22; P = 0.01) complications were higher than those of relatively younger patients. The overall postoperative complication rate (OR 1.40, 95% CI 0.82-2.40; P = 0.22) and the incidence of anastomotic leak (OR 0.92, 95% CI 0.58-1.47; P = 0.73) were not significantly different between the 2 groups. Elderly patients had a worse overall 5-year survival rate (HR 2.66, 95% CI 1.65-4.28; P < 0.001) than that of relatively younger patients. The cancer-related 5-year survival rate of elderly patients was also lower than that of relatively younger patients (HR 3.37, 95% CI 2.36-4.82; P < 0.001).

CONCLUSIONS

Compared with relatively younger patients, elderly patients with oesophageal cancer undergoing oesophagectomy are at higher risk of in-hospital mortality and have lower survival rates. However, there is no conclusive evidence that the overall rate of complications is elevated in elderly patients.

Clinical Factors and Outcomes of Octogenarians Receiving Curative Surgery for Esophageal Cancer

BACKGROUND

The incidence of esophageal cancer is increasing in the United States. Although neoadjuvant therapy (NAT) for locally advanced cancers followed by surgical resection is the standard of care, there are no clearly defined guidelines for patients aged ≥79 y.

METHODS

Query of an institutional review board-approved database of 1031 esophagectomies at our institution revealed 35 patients aged ≥79 y from 1999 to 2017 who underwent esophagectomy. Age, gender, tumor location, histology, clinical stage, Charlson Comorbidity Index (CCI), NAT administration, pathologic response rate to NAT, surgery type, negative margin resection status, postoperative complications, postoperative death, length of stay, 30- and 90-d mortality, and disease status parameters were analyzed in association with clinical outcome.

RESULTS

The median age of the octogenarian cohort was 82.1 y with a male preponderance (91.4%). American Joint Committee on Cancer clinical staging was stage I for 20% of patients, stage II for 27% of patients, and stage III for 50% of patients, which was not statistically significant compared with the younger cohort (P = 0.576). Within the octogenarian group, 54% received NAT compared with 67% in the younger group (P = 0.098). There was no difference in postoperative complications (P = 0.424), postoperative death (P = 0.312), and recurrence rate (P = 0.434) between the groups. However, CCI was significantly different between the octogenarian and nonoctogenarian cohort (P = 0.008), and octogenarians had shorter overall survival (18 versus 62 mo, P<0.001). None of the other parameters assessed were associated with clinical outcomes.

CONCLUSIONS

Curative surgery is viable and safe for octogenarians with esophageal cancer. Long-term survival was significantly shorter in the octogenarian group, suggesting the need for better clinical selection criteria for esophagectomy after chemoradiation and that identification of complete responders for nonoperative management is warranted.

Outcomes of octogenarians with esophageal cancer: an analysis of the National Cancer Database

The optimal treatment of esophageal cancer in octogenarians is controversial. While the safety of esophagectomy has been demonstrated in elderly patients, surgery and multimodality therapy are still offered to a select group. Additionally, the long-term outcomes in octogenarians have not been thoroughly compared to those in younger patients. We sought to compare the outcomes of esophageal cancer treatment between octogenarians and non-octogenarians in the National Cancer Database (2004-2014). The major endpoints were early postoperative mortality and long-term survival. A total of 107,921 patients were identified [octogenarian-16,388 (15.2%)]. Compared to non-octogenarians, octogenarians were more likely to be female, of higher socioeconomic status, and had more Charlson comorbidities (p < 0.001 for all). Octogenarians were significantly less likely to undergo esophagectomy (11.5% vs. 33.3%; p < 0.001) and multimodality therapy (2.0% vs. 18.5%; p < 0.001), a trend that persisted following stratification by tumor stage and Charlson comorbidities. Both 30-day and 90-day mortality were higher in the octogenarian group, even after multivariable adjustment (p ≤ 0.001 for both). Octogenarians who underwent multimodality therapy had worse long-term survival when compared to younger patients, except for those with stage III tumors and no comorbidities (HR: 1.29; p = 0.153). Within the octogenarian group, postoperative mortality was lower in academic centers, and the long-term survival was similar between multimodality treatment and surgery alone (HR: 0.96; p = 0.62). In conclusion, octogenarians are less likely to be offered treatment irrespective of tumor stage or comorbidities. Although octogenarians have higher early mortality and poorer overall survival compared to younger patients, outcomes may be improved when treatment is performed at academic centers. Multimodality treatment did not seem to confer a survival advantage compared to surgery alone in octogenarians, and more prospective studies are necessary to better elucidate the optimal treatment in this patient population.

Feasibility of subtotal esophagectomy with systematic lymphadenectomy in selected elderly patients with esophageal cancer; a propensity score matching analysis

Background

The global increase in elderly populations is accompanied by an increasing number of candidates for esophagectomy. Here we aimed to determine the postoperative outcomes after subtotal esophagectomy in elderly patients with esophageal cancer.

Methods

Patients (n = 432) with who underwent curative-intent transthoracic subtotal esophagectomy with 2- or 3-field lymphadenectomies for thoracic esophageal cancer were classified as follows: non-elderly (age < 75 years, n = 373) and elderly (age ≥ 75 years, n = 59) and groups. To balance the essential variables including neoadjuvant treatment and stage of progression, we conducted propensity score analysis, and clinical characteristics, perioperative course and prognosis were compared.

Results

After two-to-one propensity score matching, 100 and 50 patients were classified in the non-elderly and elderly groups. The elderly group had more comorbidities and lower preoperative cholinesterase activities and prognostic nutrition indexes. Although incidences of postoperative pneumonia, arrhythmia and delirium were slightly increased in the elderly group, no significant differences were observed in overall incidence of postoperative complications, rates of repeat surgery and death caused by surgery, and length of postoperative hospital stay between the two groups. There were no significant differences in disease-free and disease-specific survival as well as overall survival between the two groups.

Conclusion

Older age (≥75 years) had limited impact on morbidity, disease recurrence, and survival after subtotal esophagectomy. Therefore, age should not prevent older patients from benefitting from surgery.

Treatment and clinical outcome of clinical T4 esophageal cancer: A systematic review

BACKGROUND

Survival of patients with cT4 esophageal cancer is dismal. Although the optimal treatment strategy remains to be established, two treatment options are available for cT4 esophageal cancers: definitive chemoradiation (dCRT) and induction treatment followed by conversion surgery (CS). However, little is known concerning the differences in clinical outcome between patients with T4 esophageal tumors treated with dCRT and those eventually treated with CS.

METHODS

A systematic search of the scientific literature on PubMed/MEDLINE was carried out using the keywords "T4 esophageal cancer," "invading (involving) adjacent organ," "definitive chemoradiation," "induction therapy," "salvage surgery," and "conversion surgery," obtaining 28 reports published up to July 2018.

RESULTS/CONCLUSION

We found that CS was superior to dCRT with respect to local disease control and short-term survival; however, CS was associated with relatively higher perioperative mortality and morbidity. Alternatively, although dCRT might often cause fistula formation, a clinical complete response to dCRT is likely to lead to a better prognosis. Recent advances in chemotherapeutic agents have led to triple induction chemotherapy, with docetaxel, cisplatin, and 5-fluorouracil (DCF), which has shown promise as an initial induction treatment for cT4 esophageal cancer. Indeed, this regimen could control both local and systemic disease, which enables curative resection without preoperative CRT. Moreover, some appropriate changes in perioperative management and intensive systemic chemotherapy might enhance patient outcome. Randomized controlled trials with a large sample size are needed to establish the standard treatment for cT4 esophageal cancer.

Impact of Age and Comorbidity on Choice and Outcome of Two Different Treatment Options for Patients with Potentially Curable Esophageal Cancer

Purpose

This study was designed to assess the impact of age and comorbidity on choice and outcome of definitive chemoradiotherapy (dCRT) or neoadjuvant chemoradiotherapy plus surgery.

Methods

In this population-based study, all patients with potentially curable EC (cT1N+/cT2-3, TX, any cN, cM0) diagnosed in the South East of the Netherlands between 2004 and 2014 were included. Kaplan–Meier method with log-rank tests and multivariable Cox regression analysis were used to compare overall survival (OS).

Results

A total of 702 patients was included. Age ≥ 75 years and multiple comorbidities were associated with a higher probability for dCRT (odds ratio [OR] 8.58; 95% confidence interval [CI] 4.72–15.58; and OR 3.09; 95% CI 1.93–4.93). The strongest associations were found for the combination of hypertension plus diabetes (OR 3.80; 95% CI 1.97–7.32) and the combination of cardiovascular with pulmonary comorbidity (OR 3.18; 95% CI 1.57–6.46). Patients with EC who underwent dCRT had a poorer prognosis than those who underwent nCRT plus surgery, irrespective of age, number, and type of comorbidities. In contrast, for patients with squamous cell carcinoma with ≥ 2 comorbidities or age ≥ 75 years, OS was comparable between both groups (hazard ratio [HR] 1.52; 95% CI 0.78–2.97; and HR 0.73; 95% CI 0.13–4.14).

Conclusions

Histological tumor type should be acknowledged in treatment choices for patients with esophageal cancer. Neoadjuvant chemoradiotherapy plus surgery should basically be advised as treatment of choice for operable esophageal adenocarcinoma patients. For patients with esophageal squamous cell carcinoma with ≥ 2 comorbidities or age ≥ 75 years, dCRT may be the preferred strategy.

Influence of Patients' Age in the Utilization of Esophagectomy for Esophageal Adenocarcinoma

BACKGROUND

The indication of surgical resection in esophageal cancer is often conditioned by patient's age. We aimed to assess the trends in utilization of surgical treatment for esophageal adenocarcinoma (EAC) in the United States, stratified by age groups.

METHODS

We performed a retrospective analysis of the National Cancer Institute's Surveillance, Epidemiology, and End Results program registry for the period 2004-2014. Adult patients (aged ≥18 years) diagnosed with EAC were eligible for inclusion. The yearly incidence of esophagectomy, stratified by age groups (18-49, 50-70, and >70 years old), was calculated using Poisson regression. Weighted log-binomial regression was used to compare the proportion of patients undergoing esophagectomy, within each age group. Inverse probability of treatment weights were used to account for potential confounders.

RESULTS

A total of 21,301 patients were included. During the study period, the rate of esophagectomy decreased from 34.1% to 28.2% (P = .40) in patients between 18 and 49 years old, from 38.6% to 33.3% (P = .06) in patients between 50 and 70 years old, and from 21.4% to 16.9% (P = .04) in patients older than 70 years. After accounting for patient and cancer characteristics, patients older than 70 years were 50% less likely to undergo esophagectomy compared with both patients between 18 and 49 years old (risk ratio [RR] 0.51, 95% confidence interval [CI] 0.45-0.57, P < .0001) and patients between 50 and 70 years old (RR 0.53, 95% CI 0.50-0.56, P < .0001).

CONCLUSION

Surgical resection is scarcely used in patients older than 70 years in the United States. Further investigation of surgical outcomes in elderly patients is warranted to determine if surgical treatment is underutilized in a large proportion of EAC patients.

Changes in the nutritional status of elderly patients after esophagectomy

BACKGROUND

Esophagectomy is a highly invasive procedure for patients aged > 70 years. Here, we compared the actual nutritional status of older and younger patients who underwent esophagectomy.

METHODS

A total of 118 patients who underwent radical esophagectomy between April 2013 and December 2016 were enrolled and divided into two groups based on age: group A (n = 41; ≥ 70 years) and group B (n = 77; < 70 years). Data pertaining to body mass index and nutritional variables (albumin; total cholesterol; cholinesterase; and prealbumin) were retrospectively analyzed preoperatively and at 3, 6, and 12 months postoperatively.

RESULTS

Significant preoperative between-group differences were found in the cholinesterase, albumin, and prealbumin levels. The body mass index gradually decreased over the first 12 months after surgery in both groups, without significant between-group differences. Significant differences were observed in prealbumin and cholinesterase levels at 3 months postoperatively. 1 year postoperatively, both groups showed slight improvements; however, the between-group differences were not statistically significant. Group A had a significantly lower amount of the degree of decrement of BMI and chE than group B.

CONCLUSION

Thus, patients aged > 70 years can recover within 12 months of esophagectomy.

Management of Locally Advanced and Metastatic Esophageal Cancer in the Older Population

PURPOSE OF REVIEW

This review aims to synthesise the current literature on the management of early-stage and metastatic esophageal cancers, focusing on the older population. In particular, we aim to dissect out the elderly-specific data from the relevant trials and to discuss the issues unique to this population.

RECENT FINDINGS

While surgery is the curative modality in esophageal malignancies, the CROSS, MAGIC and FLOT trials demonstrate a clear advantage to neoadjuvant therapy (chemotherapy and chemoradiotherapy). These trials, however, included few elderly patients. There is a similar lack of elderly-specific data in the metastatic setting. Esophageal malignancies remain highly lethal with increasing incidence with age. Despite the relative lack of elderly-specific data, the fit older population appear to similarly benefit from multimodal therapy in early-stage and palliative therapy in metastatic disease.

Postoperative outcomes of esophagectomy for cancer in elderly patients

BACKGROUND

The number of elderly patients with esophageal cancer is expected to increase. We aimed to determine the postoperative outcomes of esophagectomy for esophageal cancer in elderly patients.

MATERIAL AND METHODS

A retrospective, population-based analysis was performed using the National inpatient sample for the period 2000-2014. Adult patients ≥18 years old (yo) diagnosed with esophageal cancer who underwent esophagectomy during their inpatient hospitalization were included. Patients were categorized into <70 yo and ≥70 yo. Multivariable linear and logistic regressions were used to assess the potential effect of age on postoperative complications, inpatient mortality, and hospital charges.

RESULTS

Overall, 5243 patients were included, with 3699 (70.6%) <70 yo and 1544 (29.5%) ≥70 yo. The yearly rate of esophagectomies among patients ≥70 yo did not significantly changed during the study period (28.4% in 2000 and 26.3% in 2014, P = 0.76). Elderly patients were significantly more likely to have postoperative cardiac failure (odds ratio 1.59, 95% confidence interval [CI] 1.21, 2.09, P = 0.0009) and inpatient mortality (odds ratio 1.84, 95% CI 1.39, 2.45, P < 0.0001). Among the elderly patients, hospital charges were, on average, $16,320 greater (95% CI $3110, $29,530) than patients <70 yo (P = 0.02). The predicted probability of mortality increased consistently across age (1.5% in 40 yo, 2.5% in 50 yo, 3.6% in 60 yo, 5.4% in 70 yo, and 7.0% in 80 yo).

CONCLUSIONS

Elderly patients undergoing esophagectomy for cancer have a significantly higher risk of postoperative mortality and pose a higher financial burden on the health care system. Elderly patients with esophageal cancer should be carefully selected for surgery.

Definitive chemoradiation or surgery in elderly patients with potentially curable esophageal cancer in the Netherlands: a nationwide population-based study on patterns of care and survival

BACKGROUND

The aim of our study was to describe treatment patterns and the impact on overall survival among elderly patients (75 years and older) with potentially curable esophageal cancer.

MATERIAL AND METHODS

Between 2003 and 2013, 13,244 patients from the nationwide population-based Netherlands Cancer Registry (NCR) were diagnosed with potentially curable esophageal cancer (cT2-3, X, any cN, cM0, X) of which 34% were elderly patients (n = 4501).

RESULTS

Surgical treatment with or without neoadjuvant treatment remained stable among elderly patients (around the 16% between 2003 and 2013). However, among younger patients, surgical treatment increased from 60.2 to 67.0%. The use of definitive chemoradiation (dCRT) increased in elderly patients from 1.9 to 19.5% and in younger patients from 5.2 to 17.2%. Due to the increase in dCRT, treatment with curative intent doubled in the elderly from 17 to 37.1%. Multivariable Cox regression revealed that elderly patients with an adenocarcinoma receiving surgery alone or dCRT had a significantly worse overall survival compared to those receiving surgery with neoadjuvant chemo (radio) therapy (nCRT/CT) (HR: 1.7 95% CI 1.4-2.0 and HR: 1.9 95% CI 1.5-2.3). However, among elderly with squamous cell carcinoma overall survival was comparable between dCRT, surgery alone and surgery with nCRT/CT.

CONCLUSIONS

Survival was comparable among elderly patients with squamous cell carcinoma who underwent surgery with nCRT/CT, surgery alone or received dCRT, while elderly patients with an adenocarcinoma who underwent surgery with nCRT/CT had a better overall survival when compared with surgery alone or dCRT. Therefore, dCRT can be considered as a reasonable alternative for surgery among potentially curable elderly patients with esophageal squamous cell carcinoma. However, in elderly patients with esophageal adenocarcinoma surgery with nCRT/CT is still preferable regarding overall survival.

Underutilization of Treatment for Regional Gastric Cancer Among the Elderly in the USA

BACKGROUND

In the USA, a quarter of elderly patients do not receive any treatment for regional gastric cancer, which results in poorer outcomes. We sought to identify factors associated with undertreatment of regional gastric cancer in this population, as well as to assess overall survival in the undertreated population.

METHODS

Elderly patients (aged ≥ 65 years) diagnosed with regional gastric cancer between 2001 and 2009 were identified from the Surveillance Epidemiology and End Results (SEER)-Medicare linked databases. Treatment was defined as receiving any medical or surgical therapy for gastric cancer. Logistic regression analysis was used to identify factors associated with failure to receive treatment. Overall survival was analyzed using the Kaplan-Meier method and Cox proportional hazard model.

RESULTS

Of 5972 patients with regional gastric cancer, 1586 (26.5%) received no treatment. Median age was 78 years; 56.1% of patients were men. On multivariable analysis, the factors strongly associated with lack of therapy were age ≥ 80 years, black race, lower education level, and diagnosis before 2007. As expected, patients who received therapy had better overall survival (log-rank test, p < 0.001). Specifically, median survival and 5-year survival were 16.5 months and 20.5% for treated patients, compared with 9.1 months and 19.0% for untreated patients.

CONCLUSIONS

Elderly patients with gastric cancer have better overall 5-year survival after receiving treatment for their cancer. Disparities in the use of treatment for curable cancers are associated with older age, black race, lower educational level, and diagnosis before 2007.

Clinical outcome of elderly patients (≥ 70 years) with esophageal cancer undergoing definitive or neoadjuvant radio(chemo)therapy: a retrospective single center analysis

BACKGROUND

To analyse the outcome of elderly patients (≥70 years) with esophageal cancer treated with curative intent radio(chemo)therapy.

METHODS

Fifty five patients (median 75 years) receiving curative intent radio(chemo)therapy for esophageal cancer from 1999 to 2015 were retrospectively analyzed. Most patients showed locally advanced disease (T3/4:78%, N+:58%) with squamous cell histology (74%). Charlson comorbidity score was > 1 in 27%. 48 patients (87%) received definitive treatment while 7 patients were treated neoadjuvantly. RT was carried out as 3D-conformal treatment or IMRT. Concurrent chemotherapy was applied in 85%, mainly cisplatin/5-FU or mitomycin/5-FU. ¹⁸FDG-PET/CT staging was used in 65%.

RESULTS

Median follow-up was 11 months (1-68) and 21 months in survivors. 1- and 2-year rates of LRC, DC, FFTF and OS were 60%/45, 81%/72, 55%/41 and 46%/26% for the entire cohort. In univariate analysis, addition of surgery was associated with improved LRC and FFTF, nodal involvement with improved DC and lower T stage, lower Charlson score and use of PET-CT with improved OS. In multivariate analysis, lower T stage and lower Charlson score remained significant for OS. Patients treated after 2008 showed a significantly improved FFTF (1-year FFTF 64% vs 35%) and OS (1-year OS 66% vs 24%). Maximum (chemo)radiation related grade3+ toxicity was observed in 80% including 7 deaths (13%). Grade5 toxicity was significantly associated with Charlson score (CS > 1:33% vs CS ≤ 1:5%) and treatment period (24% before vs 3% after 2008). The patients treated after 2008 included significantly more SCCs, less T4 stages, had a higher percentage of PET-CT staging and were treated with smaller field lengths. Trends were also observed for lower Charlson scores and increased use of IMRT.

CONCLUSION

Curative intent (chemo)radiation of elderly patients with esophageal cancer may result in considerable toxicity and unfavorable outcome. However, a clear improvement over time was observed in our cohort, probably based on improved patient selection. In patients with less advanced stages and lower comorbidity similar results as in younger cohorts seem achievable with modern staging and treatment approaches. Age per se should not be a decisive factor, but careful attention should be paid regarding patient selection including a structured and tight follow-up strategy.

The impact of the Charlson comorbidity index on the prognosis of esophageal cancer patients who underwent esophagectomy with curative intent

PURPOSE

The aim of this study was to clarify the influence of Charlson comorbidity index (CCI) on treatment options, and on short- and mid-term outcomes in esophageal cancer patients who underwent esophagectomy.

METHODS

Patients who underwent curative-intent esophagectomy from 2009 to 2014 were classified by CCI. A CCI of ≥ 2 was defined as high, while a CCI of 0 or 1 was classified as low. Clinicopathological parameters, including overall survival (OS) and disease-specific survival (DSS), were compared between the groups.

RESULTS

Among 548 patients, the most frequent comorbidity was chronic obstructive pulmonary disease (n = 142, 25.9%), followed by solid tumor (n = 79, 14.4%). A high CCI was significantly correlated with older age (P < 0.001), surgery alone (P = 0.020), a lower number of dissected lymph nodes (P < 0.001), lower rate of R0 resection (P = 0.048), and prolonged hospital stay (P < 0.001). In the low group, OS after surgery was favorable in comparison to the the high group. Although DSS was comparable between the groups, the CCI was significantly associated with a poor prognosis in patients with stage ≥ II disease.

CONCLUSIONS

The CCI was significantly correlated with the prognosis of esophageal cancer patients who underwent curative-intent esophagectomy.

Hand grip strength as a predictor of postoperative complications in esophageal cancer patients undergoing esophagectomy

BACKGROUND

Radical esophagectomy remains the primary treatment option for resectable esophageal cancer. However, it sometimes induces postoperative complications due to its invasive nature. Recently, the impact of loss of muscle mass on postoperative complications and survival among cancer patients has been highlighted. This study aimed to identify the impact of low hand grip strength (HGS) on postoperative complications after esophagectomy.

METHODS

A total of 188 patients (male: 166, female: 22) who underwent radical esophagectomy with gastric tube reconstruction between 2008 and 2014 were included. The correlation between HGS and age was analyzed using Pearson's correlation coefficient. Due to the small patient numbers, only male patients were stratified into two groups according to age (<70 years: non-elderly group, ≥70 years: elderly group). Receiver operating characteristic curve analysis was performed for each group using postoperative complication occurrence as the endpoint to determine an optimal HGS cutoff value.

RESULTS

Postoperative complications occurred in 60.9% of the elderly group and 47.4% of the non-elderly group. When the cutoff values were set at 30.5 and 37 kg for the elderly and non-elderly group, respectively, low HGS was an independent predictive factor of postoperative complications on multivariate analysis only in the elderly group (p = 0.008). In the elderly group, the incidence of postoperative pneumonia was 39.5% among patients with low HGS vs. 3.8% among patients with high HGS.

CONCLUSION

Preoperative HGS is an independent predictive factor of postoperative complications, especially postoperative pneumonia, for elderly male patients with esophageal cancer treated with radical esophagectomy.

Outcome of esophageal cancer in the elderly - systematic review of the literature

Introduction

As the population ages, the number of elderly patients with esophageal cancer increases. Esophageal cancer has a poor prognosis and is associated with decreased life quality.

Aim

To review the literature about the outcome of esophageal cancer in patients over 65.

Material and methods

Articles published between January 2006 and November 2016 in the PubMed/Medline and ResearchGate databases were reviewed. Nineteen retrospective studies were included.

Results

Six thousand seven hundred and twenty-nine patients over 65 were analyzed. Thirty-day mortality ranges from 3.2% to 8.1%. Overall 5-year survival rates range from 0% to 49.2%, and the median survival rate ranges from 9.6 to 108.2 months. The incidence of complications in the surgery group ranges from 27% to 69%. Chemoradiotherapy grade ≥ 3 toxicity was observed in 22-36% of patients.

Conclusions

Chronological age seems to have little influence on outcome of esophageal cancer. Open esophagectomy seems to be the mainstay of treatment for patients with esophageal cancer, regardless of age. There is still high mortality and morbidity involved in this procedure. To reduce them, some less invasive methods are being trialed.

Impact of Sarcopenia on Unplanned Readmission and Survival After Esophagectomy in Patients with Esophageal Cancer

BACKGROUND

Although sarcopenia increases postoperative complications following esophagectomy, its effects on prognosis remain unclear. This study was performed to identify the effect of sarcopenia on 90-day unplanned readmission and overall survival (OS) after esophagectomy.

METHODS

Ninety-eight patients with esophageal cancer who underwent esophagectomy were enrolled in this study. Unplanned readmission was defined as any emergent hospitalization within 90 days after discharge. Sarcopenia, defined as low muscle mass plus low muscle strength and/or low physical performance according to the Asian consensus definition, was assessed prior to esophagectomy. Multivariate logistic regression analysis was performed to identify factors that contributed to 90-day unplanned readmission. OS was estimated using the Kaplan-Meier method, and a Cox proportional hazards model was used to assess the relationship between sarcopenia and OS.

RESULTS

Thirty-one patients (31.6%) were diagnosed with sarcopenia. The 90-day unplanned readmission rate was significantly higher in patients with sarcopenia than those without (42.9% vs. 16.4%, respectively; p = 0.01). Multivariable logistic regression analysis showed that sarcopenia was an independent predictor of 90-day unplanned readmission [odds ratio 3.71, 95% confidence interval (CI) 1.29-11.05; p = 0.02], and the log-rank test showed that sarcopenia was associated with OS (p = 0.01). Moreover, sarcopenia was a significant predictor of OS after adjustment for age, sex, and pathological stage (hazard ratio 2.35, 95% CI 1.21-4.54; p = 0.01).

CONCLUSIONS

Sarcopenia is a risk factor for 90-day unplanned readmission and OS following esophagectomy. Assessment of sarcopenia could help to identify patients at higher risk of a poor prognosis after esophagectomy.

The use of neoadjuvant therapy for resectable locally advanced thoracic esophageal squamous cell carcinoma in an analysis of 5016 patients from 305 designated cancer care hospitals in Japan

BACKGROUND

Recent studies have shown the benefits of neoadjuvant therapy with chemotherapy or chemoradiotherapy for resectable locally advanced thoracic esophageal squamous cell carcinoma (ESCC). The aim of our study was to elucidate the use of neoadjuvant therapy for thoracic ESCC in Japan.

METHODS

Data on patients with stage IB-III thoracic ESCC were retrieved from the national database of hospital-based cancer registries combined with claims data between 2012 and 2013. These data were analyzed using a mixed-effect logistic regression analysis, with a focus on exploring patterns in the first-line treatment for ESCC, including proportion of patients who received neoadjuvant therapy, and investigating the hospital characteristics and patient factors associated with the use of neoadjuvant therapy.

RESULTS

Of the 5016 patients with stage IB-III thoracic ESCC at the 305 participating hospitals, 34.2% received neoadjuvant therapy (neoadjuvant chemotherapy, 29.5%; neoadjuvant chemoradiotherapy, 4.7%). The therapy was less likely to be administered to older patients (≤64 years, 48.8%; 65-70 years, 42.0%; 70-75 years, 33.9%; 75-80 years, 22.2%; 80-85 years, 3.8%; ≥85 years, 1.4%) and at hospitals with a low volume of patients (very high, 42.1%; high, 37.5%; low, 30.7%; and very low, 26.4%). This trend was confirmed by regression analysis.

CONCLUSIONS

Based on our results, in Japan, relatively few patients with resectable locally advanced thoracic ESCC receive neoadjuvant therapy, with older patients and patients at lower volume hospitals being less likely than other patients to receive the neoadjuvant therapy. We recommend that the process of treatment decision-making be assessed at both the patient and hospital levels so that patients can consider various treatment options, including neoadjuvant therapy with surgery in Japan.

Comparison of right- and left-approach esophagectomy for elderly patients with operable thoracic esophageal squamous cell carcinoma: a propensity matched study

BACKGROUND

the right- and left-approach open esophagectomies remain the general procedures among patients with operable thoracic esophageal squamous cell carcinoma (ESCC). The choice between the two approaches for elderly patients is controversial.

METHODS

we performed a 1:1 propensity score matching (PSM) analysis to compare the impact of right- and left-approach esophagectomies on survival and perioperative complications of elderly ESCC patients. Patients aged over 70 receiving esophagectomy to treat the thoracic ESCC were retrospectively retrieved.

RESULTS

a total of 276 patients were included in the study. Among them, 75 (27.2%) patients received right-approach esophagectomy. After match, 114 patients (57 pairs) undertook right or left-approach esophagectomy displayed no difference among clinicopathological characteristics. Both the overall survival (54.6% vs. 32.6%, P=0.036) and disease-free survival (52.7% vs. 20.2%, P=0.021) were significant better in right-approach group, along with better lymph node resection, and lower incidence of recurrence. However, increased incidences of postoperative pneumonia (P=0.040), respiratory failure (P=0.028), and sub-clinical anastomotic leak (P=0.032) were found in right-approach group as well, although the perioperative mortality was similar between groups.

CONCLUSIONS

Right-approach esophagectomy should be accepted as a preferential surgical approach for elderly patients with ESCC.

Impact of neoadjuvant chemotherapy and chemoradiotherapy on postoperative cardiopulmonary complications in patients with esophageal cancer

The effectiveness of neoadjuvant chemotherapy (nCT) or chemoradiotherapy (nCRT) for esophageal cancer patients is well established. However, neoadjuvant therapy may induce severe adverse effects that could increase postoperative morbidity. The current study evaluated the impacts of nCT and nCRT on postoperative cardiopulmonary complications in patient with esophageal cancer. We conducted a prospective study in esophageal cancer patients who received nCT (n  =  126) or nCRT (n  =  141) prior to surgery. Surgery was performed in all these patients following nCT or nCRT treatment. More patients occurred pneumonia in the nCRT-treated group compared with the nCT group (P < 0.01). The E-velocity (early diastolic filling velocity) decreased significantly (P = 0.026), while the N-terminal pro-brain natriuretic peptide (NT-proBNP) significantly increased (P < 0.01) in patients of the nCRT group compared with patients from the nCT group. Furthermore, a multivariate analysis revealed that nCRT was correlated with the incidence of pneumonia and NT-proBNP level significantly. The nCRT caused more cardiopulmonary toxicity than nCT. The strategies are needed to prevent the postoperative cardiopulmonary complications especially in patients with nCRT treatment.

Definitive Chemoradiation Therapy for Esophageal Cancer in the Elderly: Clinical Outcomes for Patients Exceeding 80 Years Old

PURPOSE

The optimal treatment approach for patients ≥80 years ("elderly") with esophageal cancer is not well established. We assessed the clinical outcomes in elderly patients treated with definitive chemoradiation therapy (CCRT) at our institution.

METHODS AND MATERIALS

56 consecutive patients ≥80 years with esophageal cancer treated with conventional CCRT between 2001 and 2016 were propensity score matched 1:2 to generate 2 younger patient cohorts treated with CCRT without surgery: "intermediate" (65-79 years, n=112) and "younger" (<65 years, n=112). Treatment related toxicity was assessed using the Common Terminology Criteria for Adverse Events version 4.0. The rates of overall survival (OS) and recurrence-free survival (RFS) were calculated with the Kaplan-Meier method.

RESULTS

The median ages of the 3 cohorts were 81 years (elderly, 80-92 years), 71 years (intermediate, 65-79 years), and 58 years (younger, 20-64 years). The elderly cohort was more likely to have cardiac comorbidities. Although the clinical complete response (cCR) rate deviated significantly among the 3 cohorts, (78%, 72%, and 56%; P=.004), the data failed to identify statistically significant differences among RFS, 2-year, and 5-year OS, or in median survival, which was 15.5 months, 23.6 months, and 20.2 months (P=.468), respectively. The overall severe toxicity rates were 38%, 32%, and 30%, respectively (P=.644), including comparable rate of radiation pneumonitis (P>.05). The elderly cohort, however, did show statistically significant evidence of an increased rate of severe radiation pneumonitis (grade ≥3) which was observed to be 11% versus 4% and 0%, respectively (P=.003).

CONCLUSIONS

The studied elderly population showed evidence of similar long-term clinical efficacy after definitive CCRT when compared with cohorts of younger patients with similar prognostic status. An increased rate of pulmonary toxicity was identified, without evidence of differences for nonpulmonary severe adverse events. Understanding the prognostic risk factors of pulmonary toxicity after CCRT may effectuate improved long-term outcomes for elderly population.

Esophageal Cancer Treatment Is Underutilized Among Elderly Patients in the USA

OBJECTIVES

Large numbers of elderly patients in the USA receive no treatment for esophageal cancer, despite evidence that multimodality treatment can increase survival. Our goal is to identify factors that may contribute to lack of treatment.

MATERIALS AND METHODS

Using Surveillance Epidemiology and End Results (SEER)-Medicare Linked Database (2001-2009), we identified regional esophageal cancer patients ≥65 years old. Treatment was defined as receiving any medical or surgical therapy for esophageal cancer. Logistic regression analysis was performed to identify factors associated with failure to receive treatment. Overall survival (OS) was analyzed using the Kaplan-Meier method and Cox proportional hazard model.

RESULTS

There were 5072 patients (median age, 75 years; interquartile range (IQR), 71-81 years). Majority were treated with definitive chemoradiation (48.49 %). Factors associated with lack of treatment included West geographic region and ≥80 years old. Patients who received therapy had better OS (log-rank, p < 0.001). Compared with treated patients, non-treated patients had worse adjusted OS (HR, 1.43; 95 % confidence interval (CI), 1.33-1.55; p < 0.001).

CONCLUSIONS

Elderly patients with locally advanced esophageal cancer who received treatment had improved 5-year survival compared with patients without treatment. Disparities in utilization of treatment are associated with regional and socioeconomic factors, not presence of comorbidities.

Surgical and long-term outcomes following oesophagectomy in oesophageal cancer patients with comorbidity

INTRODUCTION

The elucidation of the clinical impact of comorbidities is important to optimize the treatment and follow-up strategy in oesophageal cancer. We aimed to clarify the surgical and long-term outcomes following oesophagectomy in oesophageal cancer patients with comorbidity.

METHODS

A total of 658 consecutive patients who underwent oesophagectomy for oesophageal cancer between 1985 and 2008 at our institution were enrolled. Based on the criteria of comorbidity as we defined it, we retrospectively reviewed and compared the surgical outcomes and survival between the comorbid (n = 251) and non-comorbid group (n = 407).

RESULTS

Postoperative morbidity and mortality were not significantly different between the two groups. The 5-year overall survival rate of the comorbid group was significantly lower (39.3% vs. 45.2%, adjusted HR = 1.31, 95% CI: 1.07-1.62) but the 5-year disease-specific survival rate was not significantly different between the comorbid and non-comorbid groups (53.9% vs. 53.1%, adjusted HR = 1.11, 95% CI: 0.86-1.42). The 5-year incidence rate of death from other diseases in the comorbid group was significantly higher than that in the non-comorbid group (26.7% vs. 14.8%, P < 0.01). The leading cause of death from other diseases was pneumonia.

CONCLUSIONS

Oesophagectomy in oesophageal cancer patients with comorbidity can be safely performed. However, the overall survival after oesophagectomy in these patients was unfavorable because of the high incidence of death from other diseases, especially pneumonia.

Achieving long term survival in oesophagectomy patients aged over 75

AIMS

Surgical resection is often the only curative treatment for oesophageal cancer. The aim of this retrospective cohort study was to analyse outcomes following oesophageal resection in patients aged 75 years and older and the impact of an Enhanced Recovery after Surgery (ERAS) program in this cohort.

METHODS

Patients aged over 75 years undergoing oesophagectomy between 2003 and 2013 were identified from a single centre using an electronic database. Data on pre-operative comorbidity, tumour stage and length of hospital stay (LOS) were collected. Complications were classified according to the Clavien-Dindo system. Thirty day, 1- and 5-year mortality rates were calculated.

RESULTS

147 patients were identified with a median age of 78.5 (IQR 76.7-80.9). 33% (n = 44) had a grade 3 complication or higher. Median LOS in hospital was 16 days (IQR 13.0-22.0). Thirty-day mortality was 3.4%, 1-year and 5-year survival was 65% and 21% respectively. 45% of patients were enrolled into an Enhanced Recovery After Surgery program and they demonstrated a significantly reduced length of stay from 18 to 14 days (p = 0.005) and 30-day mortality from 6.2% to 0% (p = 0.04) compared to the time period before the program.

CONCLUSION

Long-term survival is achievable in patients aged over 75 years.

Which factors are associated with extremely short-term survival after surgery in patients with esophageal squamous cell carcinoma?

AIMS

Esophageal squamous cell carcinoma (ESCC) is associated with a short median survival and low cure rates. The postoperative survival time of some patients with ESCC is extremely short. It is important to understand risk factors in subsets of patients associated with extremely short-term survival. The standard factors such as T and N stage, which are predictive of actuarial survival, become less important as patients live for ≤1 year. However, the prevalence of these factors in these patient populations has not been well documented. We evaluated factors predictive of ≤1 year survival in this research.

METHODS

We analyzed 1596 patients underwent esophagectomy for ESCC retrospectively. The demographic and clinicopathologic characteristics were compared between patients who died within 1 year of esophagectomy and patients who survived more than 1 year after esophagectomy.

RESULTS

Univariate analysis showed significant differences between the two groups regarding gender, weight loss, comorbidity, neoadjuvant treatment, completeness of resection, pathological T stage, pathological N stage, histologic grade, the number of metastatic lymph nodes, postoperative complications, postoperative pulmonary infection and postoperative hospital stay. Based on logistic regression analysis, significant factors associated with extremely short-term survival were male gender, incomplete tumor resection, higher pathological T stage, higher pathological N stage and postoperative pulmonary infection.

CONCLUSION

The independent positive predictors for extremely short-term survival are male gender, incomplete tumor resection and postoperative pulmonary infection besides higher pathological T stage and higher pathological N stage.