Outcomes of Neoadjuvant Chemotherapy Versus Chemoradiation for Esophageal Adenocarcinoma: A National Cancer Database...

While neoadjuvant chemoradiation (NCRT) has been the acceptable standard of care for esophageal adenocarcinoma (EAC), there has been a paradigm shift based on recent trials showing neoadjuvant chemotherapy (NCT) as being either equivalent or superior to NCRT. We sought to examine the outcomes of NCT versus NCRT in esophageal cancer.

Utilizing the National Cancer Database, we identified esophagectomy patients with EAC who underwent multi-agent NCT versus multi-agent NCRT. Groups were statistically equated with propensity score-matched (PSM) analysis.

After PSM, we identified 1007 patients in each group. There was improved lymphadenectomy and higher use of adjuvant therapy in the NCT group, and significant improvements in R0 resection and pathologic response associated with NCRT. There was also a significant improvement in overall survival (OS) in the NCT versus NCRT groups. The median and 5-year OS were 42.7 months and 42% in NCT versus 34.2 months and 35% in NCRT (p = 0.001). For pathologic complete responders, median and 5-year OS were 101 months and 64% in NCT versus 71.2 months and 53% in NCRT (p = 0.04). On multivariate analysis, reduced mortality was associated with female sex, pathologic N0, >10 nodes removed, pathologic partial or complete response, R0, well/moderate grade, NCT, adjuvant chemotherapy, and higher facility volume.

Despite the higher R0 rate and pathologic response associated with NCRT, NCT was associated with improved OS compared with NCRT in EAC patients. While NCT shows an OS advantage in this dataset, regimen heterogeneity precludes definitive therapeutic recommendations.