The use of trimodality therapy for the treatment of operable esophageal carcinoma in the veteran population - Patient survival and outcome analysis

BACKGROUND. in an effort to improve the cure rates associated with surgical therapy, neoadjuvant chemoradiotherapy is being used with increasing frequ ency before resection (trimodality therapy). A variety of clinical trials h ave reviewed this approach, but only one study to the authors' knowledge ha s shown a survival benefit for trimodality therapy. The extent to which tri modality therapy has gained acceptance in general practice is not clear. Th e objective of the current study was to determine the extent to which both surgery and trimodality therapy are used for the management of esophageal c arcinoma within a large, national health care system and to determine the o utcome of patients treated with these treatment approaches. METHODS. The current study was a retrospective cohort study. The study popu lation was comprised of all veterans who underwent either surgery alone or trimodality therapy for operable esophageal carcinoma between the fiscal ye ars of 1993 and 1997. Data were obtained from the Veterans Administration P atient Treatment File, Outpatient Clinic File, and the Beneficiary Identifi cation Record Locator System. The main outcome measures were perioperative mortality and patient survival. RESULTS. During the study period, 695 patients underwent either surgery alo ne or trimodality therapy for esophageal carcinoma. Five hundred thirty-fou r (77%) patients were treated with surgery only. One hundred sixty-one (23% ) patients underwent surgery after induction ch emo radiotherapy (trimodali ty therapy). Patients selected for trimodality therapy were younger (mean a ge, 60.8 years vs. 65.6 years), had fewer comorbidities, and were more like ly to have a midesophageal tumor. The median survival for all patients was 15.2 months. The type of treatment had no apparent effect on survival. Favo rable prognostic factors included younger age, a distal esophageal tumor, a nd the absence of metastases. The overall perioperative mortality was 13.7% . The use of trimodality therapy did not increase perioperative mortality. CONCLUSIONS. Trimodality therapy is commonly used within the VA system. The nonrandomized nature of this study does not allow comparison of trimodalit y therapy to surgery alone, but the overall survival was limited for all pa tients. The predictors of survival are related to the biology of the diseas e, and they include patient age, tumor location, and stage at diagnosis. Pu blished 2001 by the American Cancer Society.