Should esophageal cancer follow-up ever end?

Key clinical point: Patients who achieve 5-year disease-free survival after esophagectomy for cancer should continue on follow-up beyond 5 years.

Major finding: After 5 years of disease-free survival, 6.3% of patients had recurrence of esophageal cancer, 18% had a second cancer elsewhere, and 7.9% died of pulmonary-related problems.

Data source: Retrospective review of a prospectively assembled thoracic surgery database of 355 patients who had esophagectomy for cT2N0M0 esophageal cancer from 1988 to 2009.

Disclosures: Coauthor Dr. Paul J. Christos disclosed partial support of a grant from Cornell University, New York. The other authors had no relationships to disclose.

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Go long with post-esophagectomy care

The study by Dr. Ghaly and colleagues “provides some much-needed good news in esophageal cancer,” Dr. Gail Darling of the University of Toronto said in her invited commentary (J Thorac Cardiovasc Surg. 2016 Mar;151:733-4). She noted that 5-year survival after esophagectomy was once considered a cure, but increased survival after 5 years thanks to the use of neoadjuvant therapy raises the question: Has it simply delayed recurrence?

Dr. Gail Darling

The study has shown that not all patients are cured even if they’re disease-free after 5 years, Dr. Darling said, making the case for follow-up beyond 5 years. Besides the risk of recurrence of esophageal cancer, a second reason for longer-term follow-up is the risk of second cancers. “This paper reminds us that we should not give up on our patients,” Dr. Darling said. “What a terrible thing it would be to be cured of one of the deadliest cancers, only to die from one that is more often curable.”

The role of pulmonary disease as a leading cause of death in these patients after 5 years cannot be ignored either, she said. People who have had esophagectomy often have chronic cough and reflux, and 25% of 5-year survivors had preexisting pulmonary disease. “Did patients die of their preexisting pulmonary disease, or did chronic reflux and aspiration contribute to their deaths?” she asked. “Perhaps chronic reflux is more than a quality-of-life issue.”

Dr. Darling acknowledged the study delivers “some much needed good news in esophageal cancer.” At the same time, “much work needs to be done.” That work includes addressing surgical quality. “We count lymph nodes and measure margins,” she said. “Is this enough? Is en bloc esophagectomy the answer?” The infrequency of esophageal cancer probably obviates a randomized trial, but the capabilities for collaborating on data collection and analysis provide an opportunity to determine the best surgical approach, she said. “At that point, the task of delivering high-quality surgery will rest with us.”

Dr. Darling had no financial relationships to disclose.




About one third of patients who have esophagectomy for locally advanced esophageal cancer can survive disease-free for 5 years or longer, and once they reach that milestone, they have a good chance of living another 5 years, but previous studies have not explored if these patients continue disease-free or determined any independent predictors for long-term survival.

To get answers, investigators at Cornell University, New York conducted a retrospective review of a prospective database of 355 patients who underwent esophagectomy for cT2N0M0 or higher disease between 1988 and 2009, 126 of whom were alive and disease-free after 5 years.

The actuarial overall survival of this group was 94% at 7 years and 80% at 10 years, according to results published in the March issue of the Journal of Thoracic and Cardiovascular Surgery (2016 Mar;151:726-32). The findings were first presented at the 95th annual meeting of the American Association for Thoracic Surgery in April 2015 in Seattle. A video of the presentation is available at the AATS website (

The 33% disease-free survival rate of these patients is “promising,” Dr. Galal Ghaly and colleagues said. “These excellent results are likely the result of accurate preoperative staging, standardization of surgical and perioperative management, and the use of multimodality treatment strategies,” they said.

But even after 5 years without disease, these patients were at risk of recurrence or other problems. Twenty-three patients (18%) experienced a second primary cancer elsewhere and eight (6.3%) had recurrence of esophageal cancer. Pulmonary-related deaths accounted for 10 (7.9%) of 22 (17.5%) non-cancer deaths after 5 years. “Careful follow-up is necessary for these patients, even after the 5-year mark,” Dr. Ghaly and colleagues said.

The study identified en bloc resection as the sole independent predictor of disease-free survival in these patients, a finding the investigators called “surprising,” but one with an explanation: “It is possible that patients undergoing en bloc resection were selected for that surgical procedure because of better performance status, fewer comorbidities or less frail appearance,” Dr. Ghaly and colleagues said. “Such a group might be expected to have a longer [overall survival] on the basis of those differences alone.”

Dr. Ghaly and coauthors acknowledged that over the 20-year term of the study changes in treatment approaches could have influenced patient outcomes, but a multivariable analysis accounted for that. They did find variability in preoperative staging, however. “Another limitation is the lack of a consistent method of preoperative staging, with 55% to 63% of patients staged by endoscopic ultrasonography and PET scanning,” Dr. Ghaly and coauthors said. However, that only resulted in 13 patients (10%) eventually found to have pT1N0 disease, and the results remained the same after those patients were excluded from the analysis.

Coauthor Dr. Paul J. Christos disclosed he had received a grant from the Clinical and Translational Science Center at Cornell University, New York. The other coauthors had no financial relationships to disclose.

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