©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Sep 27, 2020; 12(9): 377-389
Published online Sep 27, 2020. doi: 10.4240/wjgs.v12.i9.377
Impact of palliative therapies in metastatic esophageal cancer patients not receiving chemotherapy
Sungjin Kim, Timothy P DiPeri, Michelle Guan, Veronica R Placencio-Hickok, Haesoo Kim, Jar-Yee Liu, Andrew Hendifar, Samuel J Klempner, Ryan Nipp, Alexandra Gangi, Miguel Burch, Kevin Waters, May Cho, Joseph Chao, Katelyn Atkins, Mitchell Kamrava, Richard Tuli, Jun Gong
Sungjin Kim, Biostatistics and Bioinformatics Research Center, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
Timothy P DiPeri, Alexandra Gangi, Miguel Burch, Division of Surgical Oncology, Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
Michelle Guan, Veronica R Placencio-Hickok, Haesoo Kim, Jar-Yee Liu, Andrew Hendifar, Jun Gong, Department of Medicine, Division of Hematology and Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, Los Angeles, CA 90048, United States
Samuel J Klempner, Ryan Nipp, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA 02114, United States
Kevin Waters, Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
May Cho, Division of Hematology and Oncology, Department of Medicine, University of California, Davis, Sacramento, CA 95817, United States
Joseph Chao, Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, United States
Katelyn Atkins, Mitchell Kamrava, Department of Radiation Oncology, Cedars Sinai Medical Center, Los Angeles, CA 90048, United States
Richard Tuli, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
Author contributions: Kim S and Gong J designed the research; Kim S, Guan M, Placencio-Hickok VR, Kim H, Liu JY, and Gong J collected and analyzed the data; Kim S, DiPeri TP, and Gong J wrote the paper; all authors edited and approved the final paper.
Institutional review board statement: The data used in the study are derived from a de-identified National Cancer Database file. As all patient identification variables have been removed, no institutional review board (IRB) review was needed.
Informed consent statement: The data used in the study are derived from a de-identified National Cancer Database file. As all subject identification variables have been removed, no informed consent was needed.
Conflict-of-interest statement: No conflict of interest.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Jun Gong, MD, Assistant Professor, Department of Medicine, Division of Hematology and Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, AC 1042B, Los Angeles, CA 90048, United States. email@example.com
Received: June 3, 2020
Peer-review started: June 3, 2020
First decision: June 15, 2020
Revised: July 2, 2020
Accepted: September 8, 2020
Article in press: September 8, 2020
Published online: September 27, 2020
Palliative therapy has been associated with improved overall survival (OS) in several tumor types. Not all patients with metastatic esophageal cancer receive palliative chemotherapy, and the roles of other palliative therapies in these patients are limited.
To investigate the impact of other palliative therapies in patients with metastatic esophageal cancer not receiving chemotherapy.
The National Cancer Database was used to identify patients between 2004-2015. Patients with M1 disease who declined chemotherapy and had known palliative therapy status [palliative therapies were defined as surgery, radiotherapy (RT), pain management, or any combination thereof] were included. Cases with unknown chemotherapy, RT, or nonprimary surgery status were excluded. Kaplan-Meier estimates of OS were calculated. Cox proportional hazards regression models were employed to examine factors influencing survival.
Among 140234 esophageal cancer cases, we identified 1493 patients who did not receive chemotherapy and had complete data. Median age was 70 years, most (66.3%) had a Charlson Comorbidity Index (CCI) of 0, and 37.1% were treated at an academic center. The majority (72.7%) did not receive other palliative therapies. On both univariate and multivariable analyses, there was no difference in OS between those receiving other palliative therapy (median 2.83 mo, 95%CI: 2.53-3.12) vs no palliative therapy (2.37 no, 95%CI: 2.2-2.56; multivariable P = 0.290). On univariate, but not multivariable analysis, treatment at an academic center was predictive of improved OS [Hazard ratio (HR) 0.90, 95%CI: 0.80-1.00; P = 0.047]. On multivariable analysis, female sex (HR 0.81, 95%CI: 0.71-0.92) and non-black, other race compared to white race (HR 0.72, 95%CI: 0.56-0.93) were associated with reduced mortality, while South geographic region relative to West region (HR 1.23, 95%CI: 1.04-1.46) and CCI of 1 relative to CCI of 0 (HR 1.17, 95%CI: 1.03-1.32) were associated with increased mortality. Higher histologic grade and T-stage were also associated with worse OS (P < 0.05).
Palliative therapies other than chemotherapy conferred a numerically higher, but not statistically significant difference in OS among patients with metastatic esophageal cancer not receiving chemotherapy. Quality of life metrics, inpatient status, and subgroup analyses are important for examining the role of palliative therapies other than chemotherapy in metastatic esophageal cancer and future studies are warranted.
Core Tip: We evaluated the impact of non-chemotherapy-based palliative treatments in patients with metastatic esophageal cancer not receiving chemotherapy. A remarkably small fraction of these patients does not receive any palliative therapy. These findings merit further investigation to identify those at greatest risk who may benefit from risk-tailored management approaches. There was a numerically higher but not statistically significant difference in overall survival among those who received other palliative therapies vs those who did not (median overall survival 2.83 mo vs 2.37 mo). Our analysis was limited by lack of ability to account for patients at different stages of presentation or severity of disease.