Treatment utilization and outcomes in elderly patients with locally advanced esophageal carcinoma: a review of the National Cancer Database

Gregory Vlacich, Pamela P Samson, Stephanie M Perkins, Michael C Roach, Parag J Parikh, Jeffrey D Bradley, A Craig Lockhart, Varun Puri, Bryan F Meyers, Benjamin Kozower, Cliff G Robinson, Gregory Vlacich, Pamela P Samson, Stephanie M Perkins, Michael C Roach, Parag J Parikh, Jeffrey D Bradley, A Craig Lockhart, Varun Puri, Bryan F Meyers, Benjamin Kozower, Cliff G Robinson

Abstract

For elderly patients with locally advanced esophageal cancer, therapeutic approaches and outcomes in a modern cohort are not well characterized. Patients ≥70 years old with clinical stage II and III esophageal cancer diagnosed between 1998 and 2012 were identified from the National Cancer Database and stratified based on treatment type. Variables associated with treatment utilization were evaluated using logistic regression and survival evaluated using Cox proportional hazards analysis. Propensity matching (1:1) was performed to help account for selection bias. A total of 21,593 patients were identified. Median and maximum ages were 77 and 90, respectively. Treatment included palliative therapy (24.3%), chemoradiation (37.1%), trimodality therapy (10.0%), esophagectomy alone (5.6%), or no therapy (12.9%). Age ≥80 (OR 0.73), female gender (OR 0.81), Charlson-Deyo comorbidity score ≥2 (OR 0.82), and high-volume centers (OR 0.83) were associated with a decreased likelihood of palliative therapy versus no treatment. Age ≥80 (OR 0.79) and Clinical Stage III (OR 0.33) were associated with a decreased likelihood, while adenocarcinoma histology (OR 1.33) and nonacademic cancer centers (OR 3.9), an increased likelihood of esophagectomy alone compared to definitive chemoradiation. Age ≥80 (OR 0.15), female gender (OR 0.80), and non-Caucasian race (OR 0.63) were associated with a decreased likelihood, while adenocarcinoma histology (OR 2.10) and high-volume centers (OR 2.34), an increased likelihood of trimodality therapy compared to definitive chemoradiation. Each treatment type demonstrated improved survival compared to no therapy: palliative treatment (HR 0.49) to trimodality therapy (HR 0.25) with significance between all groups. Any therapy, including palliative care, was associated with improved survival; however, subsets of elderly patients with locally advanced esophageal cancer are less likely to receive aggressive therapy. Care should be taken to not unnecessarily deprive these individuals of treatment that may improve survival.

Keywords: Definitive chemoradiation; elderly; locally advanced esophageal cancer; palliative treatment; trimodality.

© 2017 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.

Figures

Figure 1
Figure 1
Consort diagram.
Figure 2
Figure 2
Kaplan–Meier overall survival for elderly patients with locally advanced esophageal cancer stratified by type of treatment.
Figure 3
Figure 3
Kaplan–Meier overall survival for elderly patients with locally advanced squamous cell carcinoma (A) or adenocarcinoma (B) of the esophagus stratified by type of treatment. *P value for only the comparison between esophagectomy alone and definitive concurrent chemoradiation in squamous cell carcinoma patients was 0.44. All other comparisons were statistically significant.

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