Locally Advanced Esophageal Cancer Patients With Complete Clinical Response Post Neoadjuvant Chemoradiotherapy: A Markov Decision Analysis of Esophagectomy versus Active Surveillance

Adom Bondzi-Simpson; Tiago Ribeiro; Angelo Grant; Michael Ko; Natalie Coburn; Julie Hallet; Girish S Kulkarni; Biniam Kidane

doi:10.1016/j.jtcvs.2024.04.020

Locally Advanced Esophageal Cancer Patients With Complete Clinical Response Post Neoadjuvant Chemoradiotherapy: A Markov Decision Analysis of Esophagectomy versus Active Surveillance

J Thorac Cardiovasc Surg. 2024 Apr 20:S0022-5223(24)00364-7. doi: 10.1016/j.jtcvs.2024.04.020. Online ahead of print.

Authors

Adom Bondzi-Simpson¹, Tiago Ribeiro¹, Angelo Grant², Michael Ko³, Natalie Coburn⁴, Julie Hallet⁴, Girish S Kulkarni⁵, Biniam Kidane⁶

Affiliations

¹ Department of Surgery, University of Toronto, Toronto, Ontario, Canada;; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada;; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
² Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
³ Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada;; Division of Thoracic Surgery, Department of Surgery, St Joseph's Health Centre, University of Toronto, Toronto, Canada.
⁴ Department of Surgery, University of Toronto, Toronto, Ontario, Canada;; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada;; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada;; Division of Surgical Oncology, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
⁵ Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada;; Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Canada.
⁶ Section of Thoracic Surgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada;. Electronic address: bkidane@hsc.mb.ca.

PMID: 38649112
DOI: 10.1016/j.jtcvs.2024.04.020

Abstract

Objective: Chemoradiation followed by esophagectomy is a standard treatment option for locally advanced esophageal cancer (LAEC) patients. Esophagectomy is a high-risk procedure, and recent evidence suggests select patients may benefit from omitting or delaying surgery. This study aims to compare surgery versus active surveillance for LAEC patients with complete clinical response (cCR) after neoadjuvant chemoradiotherapy (nCRT).

Methods: Decision analysis with Markov modelling was utilized. The base case was a 60-year-old male with T3N0M0 esophageal cancer with cCR after nCRT. The decision was modelled for a 5-year time horizon. Primary outcomes were life-years (LY) and quality-adjusted life-years (QALYs). Probabilities and utilities were derived through literature. Deterministic sensitivity analyses were performed using ranges from literature with consideration for clinical plausibility.

Results: Surgery was favoured for survival with an expected LY of 2.89 versus 2.64. After incorporating quality of life, active surveillance was favoured with an expected QALY of 1.70 versus 1.56. The model was sensitive to probability of recurrence on active surveillance (threshold value 0.598), probability of recurrence being resectable (0.318) and disutility of prior esophagectomy (-0.091). The model was not sensitive to perioperative morbidity and mortality.

Conclusions: Our study finds that surgery increases life expectancy but decreases quality-adjusted life years. Although the incremental change in QALY for either modality is insufficient to make broad clinical recommendations, our study demonstrates that either approach is acceptable. As probabilities of key factors are further defined in the literature, treatment decisions for patients with LAEC and a cCR after nCRT should consider histology, patient values, and quality of life.

Keywords: Complete clinical response; Decision analysis; Esophageal cancer.