195. OUTCOME OF A PATIENT CHOICE PROTOCOL OF SURGERY OR SURVEILLANCE FOR CLINICAL COMPLETE RESPONDERS TO NEOADJUVANT CHEMORADIOTHERAPY FOR ESOPHAGEAL CARCINOMA
Thomas Walsh- Gastroenterology
- General Medicine
Abstract
Background
Following neoadjuvant chemoradiotherapy (NCR) esophagectomy is mandated, regardless of response. But patients with pathological complete response (pCR) cannot benefit from resection but are exposed to its risks; and denying resection risks accusation of undertreatment of patients who succumb to recurrent disease. The majority cCR patients have a pCR. We hypothesized that offering patients a choice between surgery and surveillance would result in a non-inferior outcome. This cohort study examined the outcome of this policy.
Patients and Methods: Between 1998 and 2019, 205 patients were treated with curative intent, of whom 152 (74%) underwent NCR. They were re-staged with endoscopy, biopsy and computerized tomography (CT) six to ten weeks after completion of NCR. Of 152 so treated, 80 (52%) had a cCR. The decision to operate on cCR patients was based on patient preference. Survival time was analysed based on clinical response in all patients and with histopathological response in patients treated surgically.
Results
Of 80 (52%) patients that had a cCR 51 (64%) chose surgery and 29 (36%) chose surveillance. The mean ages of the surgery and surveillance cohorts were 59 and 70 years respectively (p < 0.001). Of 51 cCR patients undergoing surgery 35 (69%) had a pCR. The mean survival of the surgery cohort was 76 months (median 50.0; SD 74.9; range 2.2 to 268 months) compared to 56 months (median 24.6; SD 62.7; range 6.1 to 206) for surveillance. When adjusted for age, Cox regression estimated an insignificant hazard ratio of 1.22 (95% CI 0.65 to 2.32; p = 0.53).
Conclusion
Survival of cCR patients who chose surveillance was not statically inferior to those choosing surgery. This was true for both adenocarcinoma (AC) and squamous cell carcinoma (SCC). A cCR was predictive of pCR in the majority of patients. Allowing patients to choose between surveillance and surgery is prudent, especially those patients at greatest operative risk and lowest risk for residual disease.