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Trends in Treatment of T1N0 Esophageal Cancer

Semenkovich, Tara R. MD, MPHS; Hudson, Jessica L. MD, MPHS; Subramanian, Melanie MD; Mullady, Daniel K. MD; Meyers, Bryan F. MD, MPH; Puri, Varun MD, MSCI; Kozower, Benjamin D. MD, MPH

doi: 10.1097/SLA.0000000000003466

Objective: The purpose of this study was to explore nationwide trends in treatment and outcomes of T1N0 esophageal cancer.

Background: Endoscopic treatment has become an accepted option for early-stage esophageal cancer, but nationwide utilization rates and outcomes are unknown.

Methods: T1N0 esophageal cancers were identified in the National Cancer Database from 2004 to 2014. We assessed trends in treatment; compared endoscopic therapy, esophagectomy, chemoradiation, and no treatment; and performed a subgroup analysis of T1a and T1b patients from 2010 to 2014 (AJCC 7).

Results: A total of 12,383 patients with clinical T1N0 esophageal cancer were analyzed. Over a decade, use of endoscopic therapy increased from 12.7% to 33.6%, whereas chemoradiation and esophagectomy decreased, P < 0.01. The rise in endoscopic treatment of T1a disease from 42.7% to 50.6% was accompanied by a decrease in esophagectomies from 21.7% to 12.8% (P < 0.01). For T1b disease, the rise in endoscopic treatment from 16.9% to 25.1% (P = 0.03) was accompanied by decreases in no treatment and chemoradiation, whereas the rate of esophagectomies remained approximately 50%. Unadjusted median survival was longer for patients undergoing resection: esophagectomy, 98.6 months; endoscopic therapy, 77.7 months; chemoradiation, 17.3 months; no treatment, 8.2 months; P < 0.01. Risk-adjusted Cox modeling showed esophagectomy was associated with improved survival [hazard ratio (HR): 0.85], and chemoradiation (HR: 1.79) and no treatment (HR: 3.57) with decreased survival, compared to endoscopic therapy (P < 0.01).

Conclusions: Use of endoscopic therapy for T1 esophageal cancer has increased significantly: for T1a, as an alternative to esophagectomy; and for T1b, as an alternative to no treatment or chemoradiation. Despite upfront risks, long-term survival is highest for patients who can undergo esophagectomy.

Department of Surgery, Division of Cardiothoracic Surgery, Washington University in St. Louis.

This research was supported by the Barnes Jewish Hospital Foundation (TRS), National Institutes of Health (NIH) Grant Numbers 2T32HL7776 (TRS, MS) and 5T32CA009621 (JLH), and the Division of Cardiothoracic Surgery at Washington University in St. Louis.

The authors report no conflicts of interest.

Presentation: American Surgical Association 139th Annual Meeting in Dallas, TX on April 11th.

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