Evolution of Esophagectomy for Cancer Over 30 Years: Changes in Presentation, Management and Outcomes
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ORIGINAL ARTICLE – THORACIC ONCOLOGY
Evolution of Esophagectomy for Cancer Over 30 Years: Changes in Presentation, Management and Outcomes S. Michael Griffin, OBE, MD, PRCSEd1, Rhys Jones, MD, FRCS1, Sivesh Kathir Kamarajah, BMedSci, MBChB1, Maziar Navidi, MBChB, FRCSEd1, Shajahan Wahed, MD, FRCS1, Arul Immanuel, MD, FRCSEd1, Nick Hayes, FRCS1, and Alexander W. Phillips, MD, MA, FRCSEd1,2 1
Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Hospitals, Newcastle-upon-Tyne, UK; 2School of Medical Education, Newcastle University, Newcastle-upon-Tyne, UK
ABSTRACT Background. Esophageal cancer has seen a considerable change in management and outcomes over the last 30 years. Historically, the overall prognosis has been regarded as poor; however, the use of multimodal treatment and the integration of enhanced recovery pathways have improved short- and long-term outcomes. Objective. The aim of this study was to evaluate the changing trends in presentation, management, and outcomes for patients undergoing surgical treatment for esophageal cancer over 30 years from a single-center, high-volume unit in the UK. Patients and Methods. Data from consecutive patients undergoing esophagectomy for cancer (adenocarcinoma or squamous cell carcinoma) between 1989 and 2018 from a single-center, high-volume unit were reviewed. Presentation method, management strategies, and outcomes were evaluated. Patients were grouped into successive 5-year cohorts for comparison and evaluation of changing trends. Results. Between 1989 and 2018, 1486 patients underwent esophagectomy for cancer. Median age was 65 years (interquartile range [IQR] 59–71) and 1105 (75%) patients were male. Adenocarcinoma constituted 1105 (75%) patients, and overall median survival was 29 months (IQR 15–68). Patient presentation changed, with epigastric discomfort now the most common presentation (70%). An
Ó The Author(s) 2020 First Received: 29 April 2020 Accepted: 3 August 2020 A. W. Phillips, MD, MA, FRCSEd e-mail: [email protected]
improvement in mortality from 5 to 2% (p \ 0.001) was seen over the time period, and overall survival improved from 22 to 56 months (p \ 0.001); however, morbidity increased from 54 to 68% (p = 0.004). Conclusions. Long-term outcomes have significantly improved over the 30-year study period. In addition, mortality and length of stay have improved despite an increase in complications. The reasons for this are multifactorial and include the use of perioperative chemo(radio)therapy, the introduction of an enhanced recovery pathway, and improved patient selection.
Esophageal cancer is still widely regarded as a diagnosis with a poor outcome. Globally, it affects approximately 450,000 patients each year.1 Reported cure rates in the 1970s in the UK and US were only 4–5%, increasing to 15–18% by 2010.2,3 Significant changes in the management of esophageal cancer have been introduced over the past two decades. Neoadjuvant treatment is now regarded as the gold standard for those patients with locally advanc
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