E457: National Trends in Minimally Invasive Surgery for Clinical T3-4 Esophageal Cancer. A New Standard of Care for Locally Advanced Disease?

Minimally invasive esophagectomy (MIE) has demonstrated perioperative benefits for patients with esophageal cancer. For patients with locally advanced tumors, the oncologic outcomes of MIE remain controversial. Moreover, MIE is considered technically challenging. Thus, some surgeons still elect an open approach when treating patients with locally advanced disease. Here, we seek to analyze national trends and factors associated with the use of MIE for patients with cT3-4N0-3 esophageal cancer.

Methods:

Using the National Cancer Database(2010-2019) we identified patients with cT3-T4 esophageal cancer who underwent curative-intent esophagectomy. After stratifying patients by surgical approach, [Robotic(R) vs. Thoracoscopic(T) vs. Open(O)], we studied temporal trends (Mantel-Haenszel test of trend) and geographic patterns of MIE use in the United States (Chi-square test). Using multivariable logistic regression, we identified factors associated with the use of MIE.

Results:

A total of 11,326 patients with cT3-4 esophageal cancer were included, among whom 55.4%(6,273), 30.8%(3,489) and 13.8%(1,564) underwent open, thoracoscopic, and robotic approach, respectively. Among them, the median age was 64 years (IQR: 57-70), and 83.7% (9,477) were male. In the cohort, 33% (3,765) of patients were cN0, 48% (5,459) were cN1, 16% (1,765) were cN2, and 3% (337) had cN3 disease, with no difference in cN-stage among groups (p=0.67).  Over the study period, there was a 12.5% increase in the proportion of patients undergoing T, and a 24.5% increase in the proportion of patients undergoing R(p< 0.001). The increasing trend held constant for patients with both cT3 (N=10,920)(p< 0.001) and cT4 (N=406) tumors (p=0.003)(Fig-1A). Interestingly, there were differences in MIE approach among geographic regions (p< 0.001). T was used in 41.2% of cases in the Middle Atlantic, compared to 15.2% in the West North Central region, whereas R was used in 20.2% of the cases in the West South-Central, compared to 7.8% in the New England Region (Fig-1B). In multivariable analysis older age, diagnosis after 2015, treatment at an academic facility, living in a metropolitan area, cT3 tumors and receiving neoadjuvant radiotherapy associated with increased use of MIE (Fig-1C).

Conclusions:

The use of MIE for patients with locally advanced esophageal cancer has increased substantially during the last decade. We identify notable heterogeneity in treatment patterns. Given the benefits of MIE, further study is warranted to ensure equitable delivery of care to patients with esophageal cancer.