Longitudinal Follow-up of Medicare Patients After Esophageal Cancer Resection in the STS Database

Understanding characteristics associated with survival after esophagectomy for cancer is critical to preoperative risk stratification. This study sought to define predictors for long-term survival after esophagectomy for cancer in Medicare patients.

The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for patients aged ≥65 years who underwent esophagectomy for cancer between 2012 and 2020 and linked to Centers for Medicare and Medicaid Services (CMS) data using a deterministic matching algorithm. Patient, hospital, and treatment variables were assessed using a multivariable Cox proportional hazards model to evaluate characteristics associated with long-term mortality and readmission. Kaplan-Meier and cumulative incidence curves were generated and differences evaluated using the log-rank test and Gray's test, respectively.

After CMS linkage, 4798 patients were included. Thirty-day and 90-day mortality in the study group was 3.84% and 7.45%, respectively. In the multivariable model, American Society of Anesthesiologists score >3, body mass index >35, and diabetes were associated with increased mortality <90 days post-surgery, while pN/pT upstaging was associated with increased mortality >90 days post-surgery. Patients upstaged to pN(+) had a 147% increased mortality risk (adjusted hazard ratio [aHR], 2.47; 95% CI, 2.02-3.02) and those that remained pN(+) a 75% increased mortality risk (aHR, 1.75; 95% CI, 1.57-1.95) compared with downstaged patients. Patients who were pT upstaged had a 109% (aHR, 2.09; 95% CI, 1.73-2.53) increased mortality risk compared with pT downstaged patients. Risk for readmission was independent of procedure type or approach and was higher in c stage ≥2, American Society of Anesthesiologists score ≥4, and pN+.

Medicare patients undergoing esophagectomy for cancer have identifiable patient-specific predictors for short-term mortality and tumor-specific predictors for long-term mortality and readmission. In the absence of pathologic T and N downstaging, risk for long-term mortality and readmission are increased.