Five-year survivors of esophageal cancer still face low but constant risks

Patients with esophageal cancer who survive 5 years after undergoing surgery might breathe a sigh of relief and become complacent about continued monitoring. In fact, there is little published information on the outcome of patients with locally advanced esophageal cancer (LAEC) who survive beyond the 5-year mark. A study that will be presented by Brendon Stiles, MD, Associate Professor of Cardiothoracic Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, at the 95th AATS Annual Meeting finds that these survivors still face continued risks resulting from recurrence of the original cancer, appearance of new primary cancers, or chronic pulmonary disease, and calls for long-term surveillance of these patients.

Investigators from the Department of Cardiothoracic Surgery at New York-Presbyterian Hospital, Weill Cornell Medical College (New York) conducted a retrospective analysis of the health records of 355 patients with LAEC who underwent esophagectomy between January 1988 and September 2009. Most of the patients were men with adenocarcinoma of the lower esophagus and gastroesophageal junction. About half of the group (52.9%) received other therapies such as chemotherapy, chemo-radiotherapy, or radiotherapy before surgery.

Five years after surgery, 140 patients were still alive, with an absolute five-year survival rate of 39%. "This promising result likely reflects more accurate preoperative staging, improvements in surgical and perioperative management, and wider application of multimodality treatment strategies," explained Dr. Stiles.

Investigators then looked at what happened to these 140 five-year survivors over a median follow-up of 41 months (from the five-year survival point). The overall survival (OS) was 86%, 70%, and 51% for 7, 10, and 15 years, respectively. They also looked at cancer-specific survival (CSS), which they measured from the five-year point to death from esophageal cancer, and found that to be 88% at 7 years and 84% at 10 years. As of September 2014, 90 patients were disease-free, including seven patients who had been treated for recurrent esophageal cancer during the first 5 years.

Chemotherapy or radiotherapy before esophageal surgery did not have any effect on OS or CSS once patients reached the 5 year mark. The most significant predictors of mortality were tumor recurrence and less aggressive (non-enbloc) tumor resection.

Further analysis showed that 32 (23%) of the 140 survivors developed recurrent esophageal cancer. Most recurrences occurred within 5 years after surgery (24 patients) but eight patients experienced recurrence more than 5 years after surgery. Patients with recurrences were treated with chemotherapy, surgical resection, or chemoradiation); of these, 11 patients survived at least five years after treatment and six were disease free at their last check-up. Almost one third of the esophageal cancer patients who developed recurrent disease were alive 10 years later. In total, there were 20 deaths attributed to recurrent esophageal cancer. "The annualized risk of recurrence was 1.4% per year until year 10 when the CSS reaches its plateau," noted Dr. Stiles.

Four patients died from second primary cancers. Of the 23 patients who developed a second cancer, 13 developed the cancers after the five-year mark.

About one-fifth of the deaths were attributed to chronic pulmonary disease, such as chronic cough with recurrent micro-aspiration. "These potentially modifiable adverse events of esophagectomy may be mitigated by proper counseling of patients to avoid meals for two-three hours before bedtime and sleeping with the head of the bed elevated," advised Dr. Stiles. "Post-esophagectomy patients need to be followed by physicians familiar with the long-term sequellae of esophagectomy."

The results suggest that continued surveillance of esophageal cancer patients may be necessary for as long as 10 years after resection given the constant, although low risk of recurrence. Patients with nodal metastases should receive special attention, since this was found to be the only independent predictor of recurrence. "Importantly, surveillance does not appear to be futile, as 11 patients who were treated for recurrent esophageal cancer survived at least five years after treatment of their recurrence," stated Dr. Stiles.