The impact of induction chemoradiation therapy on esophageal cancer survival is controversial. The purpose of this study was to evaluate the comparative effectiveness of induction chemoradiation therapy on perioperative outcomes and long-term survival.

A retrospective study of 347 consecutive patients undergoing esophagectomies between 1999-2010 at a high-volume institution was performed. Comparison cohorts were patients treated with induction chemoradiation followed by surgery and surgery only patients. Follow-up was complete in 97% of patients. Propensity score analysis controlled for potential allocation-to-treatment bias and created matched groups. Cox proportional hazards regression evaluated differences in survival. Multivariable logistic regression and the generalized linear model determined differences in perioperative outcomes.

The majority (86%, 298/347) of patients had pretreatment endoscopic ultrasonography and PET imaging. 170 (49%) patients received induction chemoradiation therapy and 44 (26%) achieved pathologic complete response. The propensity score model performed well to create matched groups (c-index=0.88). The Cox proportional hazards regression analysis demonstrated a survival difference by treatment group (p = 0.04). Controlling for treatment bias, clinical stage and comorbidity, surgery only patients had an increased risk of five-year mortality (HR = 2.6, CI: 1.05-6.50) compared to patients treated with induction therapy. Perioperative outcomes were similar between groups (#tbl1).
Effect of Surgery Only Referent to Induction Therapy in Propensity Matched PopulationOutcomeSurgery Only (%) (median, range)Induction Therapy (%) (median, range)Surgery Only vs. Induction Therapy (P-val)95% CIIntraoperative transfusion14(7.9%)7(3.9%)OR=1.97(0.19)0.71to84.13Postoperative transfusion32(18%)18(10.1%)OR=1.62(0.17)0.81to3.23Readmission within 30 days of discharge27(15%)14(8%)OR=1.74(0.16)0.80to3.78Length of stay (d)9(3-84)9(0-75)Beta=0.27(0.79)−1.74to2.28Chest tube duration (d)7(1-62)7(3-180)Beta=−1.39(0.28)−3.95to1.1630-day mortality3(1.7%)2(1.1%)HR=0.75(0.82)0.06to9.07

In a contemporary, propensity-matched cohort, induction chemoradiation therapy for appropriate esophageal cancer patients improves long-term survival without significant increases in perioperative morbidity or mortality.