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Surgeon Age in Relation to Prognosis After Esophageal Cancer Resection

Markar, Sheraz R. MRCS, MSc, MA, PhD*,†; Mackenzie, Hugh PhD; Lagergren, Pernilla PhD*; Lagergren, Jesper PhD*,‡

doi: 10.1097/SLA.0000000000002260

Objective: It was hypothesized that patient survival improves with increasing surgeon age up to an age where it then decreases.

Background: Experience, physical and psychological abilities required for esophagectomy may change with increasing surgeon age.

Methods: This population-based cohort study included all patients having undergone esophagectomy for esophageal cancer in Sweden in 1987 to 2010, with follow-up until 2016. Risk-adjusted cumulative sum (RA-CUSUM) analysis was performed to estimate the relation between surgeon age and 90-day mortality, all-cause, and disease-specific 5-year mortality. Change-points in surgeon age identified by the RA-CUSUM were then analyzed in relation to mortality using multivariable Cox regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, sex, comorbidity, tumor stage, tumor histology, neoadjuvant therapy, surgeon volume, and calendar year.

Results: Among 139 surgeons performing 1761 esophagectomies, RA-CUSUM analysis of 90-day mortality showed change-points at 43 years (downward deflection) and at 56 years (upward deflection). Both all-cause and disease-specific 5-year mortality had corresponding change-points at 52 years and 56 years. Compared with surgeon age 52 to 55 years, surgeon age ≤51 years was associated with increased 90-day mortality (HR = 1.71, 95% CI 1.01–2.90) and 5-year all-cause mortality (HR = 1.21, 95% CI 1.02–1.43), and surgeon age ≥56 years showed increased 90-day mortality (HR = 2.38, 95% CI 1.38–4.13), 5-year all-cause mortality (HR = 1.29, 95% CI 1.08–1.55), and disease-specific 5-year mortality (HR = 1.18, 95% CI 1.01–1.42).

Conclusions: Surgeon age ≤51 and ≥56 years may increase short- and long-term mortality after esophagectomy for cancer.

*Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden

Department of Surgery and Cancer, Imperial College London, London, United Kingdom

Division of Cancer Studies, King's College London, and Guy's and St Thomas’ NHS Foundation Trust, London, United Kingdom.

Reprints: Sheraz R. Markar, MRCS, MSc, MA, PhD, Department of Molecular Medicine and Surgery, Karolinska Institutet, NS 67, 2nd Floor, 171 76 Stockholm, Sweden. E-mail:

Disclosure: The study was funded by the Swedish Research Council (839–2008–7496), the Swedish Cancer Society (CAN 2015/460). S.R.M. is supported by the National Institute of Health Research (NIHR-CTF-2015–04–09). J.L. is supported by the Karolinska Institutet Distinguished Professor Award (D-02418/2010).

The authors declare no conflicts of interest.

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