Stop Canceling Surgery for Esophageal Cancer: An Analysis of Treatment Related Mortality in 60 000 Patients

Surgical esophagectomy is falsely regarded as contributing little survival in resectable, early-stage disease in favor of nonsurgical treatment with definitive chemoradiation (dCR). We examine surgery in treatment by evaluating large-scale trends in mortality. The SEER database was queried for esophageal cancer patients from 2004 to 2020. Total of 59 754; 19 806 squamous and 34 484 adenocarcinoma. The primary outcome was the hazard ratio for overall survival defined as time from diagnosis-to-death. Differences between patients were assessed using χ2 tests for categorical variables and t-tests for continuous variables. Difference in survival by histology was assessed using Kaplan-Meier curves and Cox Proportional Hazards models. A total of 47 170 (78.9%) did not undergo surgery and 12 584 (21.1%) received surgery. The hazard ratio for patients undergoing dCR for SCC was 1.929. The hazard ratio for treatment with dCR compared to chemoradiation-followed-by-surgery (CRS) was 2.151 and for adenocarcinoma 2.386. Further analyses highlight groups under similar clinical conditions; including multivariate analysis, T-Stage, overall stage, surgical era, and surgery refusal. In every category, the risk of mortality was higher in dCR compared to CRS. Surgery combined with chemoradiation, and/or surgery alone, confers a significant survival benefit over dCR in resectable patients. Surgery should be considered early in medically fit patients with operable disease.