Michael Xiang1,2, Daniel T Chang1, Gregory M Heestand3, Erqi L Pollom4,5. 1. Department of Radiation Oncology, Stanford University, 875 Blake Wilbur Dr, Stanford, CA, 94305, USA. 2. Affiliated Physician, Palo Alto Veterans Affairs Hospital, Palo Alto, CA, USA. 3. Department of Medicine, Division of Oncology, Stanford University, Stanford, CA, USA. 4. Department of Radiation Oncology, Stanford University, 875 Blake Wilbur Dr, Stanford, CA, 94305, USA. erqiliu@stanford.edu. 5. Affiliated Physician, Palo Alto Veterans Affairs Hospital, Palo Alto, CA, USA. erqiliu@stanford.edu.
Abstract
BACKGROUND: Gastroesophageal junction (GEJ) cancers can be treated with equipoise using neoadjuvant chemoradiation (NACRT) or chemotherapy alone (NAC), but the comparative outcomes are unclear. METHODS: Patients with non-metastatic T2-4 or N1-3 GEJ adenocarcinoma who underwent definitive surgery and NAC or NACRT were selected from the National Cancer Database. The primary outcome was overall survival (OS). Multivariable regression and propensity score analysis were used to adjust for age, comorbidity, and other characteristics. RESULTS: We identified 2435 patients treated with NACRT and 648 patients treated with NAC. OS was not significantly different between NACRT and NAC (51% versus 54% at 3 years, respectively, P = 0.11). Extent of pathological downstaging (complete, partial/mixed, none) after NACRT or NAC was highly prognostic of survival. Patients with no response did equally poorly after either preoperative regimen, and NAC was significantly less likely than NACRT to produce any response (adjusted odds ratio 0.62, P < 0.0001). Rate of adjuvant chemotherapy usage was significantly lower after NACRT than after NAC (12% versus 34%, P < 0.0001). In patients with residual tumor and nodal disease, adjuvant chemotherapy was associated with higher OS after NACRT (adjusted hazard ratio 0.81, P = 0.05), but not after NAC. These results were further validated by propensity score analysis. CONCLUSIONS: NACRT had similar survival to NAC despite superior pathological downstaging. Adjuvant chemotherapy is relatively underused after NACRT and warrants further study as a risk-adapted means to improve survival, especially in patients with larger burden of residual disease.
BACKGROUND: Gastroesophageal junction (GEJ) cancers can be treated with equipoise using neoadjuvant chemoradiation (NACRT) or chemotherapy alone (NAC), but the comparative outcomes are unclear. METHODS:Patients with non-metastatic T2-4 or N1-3 GEJ adenocarcinoma who underwent definitive surgery and NAC or NACRT were selected from the National Cancer Database. The primary outcome was overall survival (OS). Multivariable regression and propensity score analysis were used to adjust for age, comorbidity, and other characteristics. RESULTS: We identified 2435 patients treated with NACRT and 648 patients treated with NAC. OS was not significantly different between NACRT and NAC (51% versus 54% at 3 years, respectively, P = 0.11). Extent of pathological downstaging (complete, partial/mixed, none) after NACRT or NAC was highly prognostic of survival. Patients with no response did equally poorly after either preoperative regimen, and NAC was significantly less likely than NACRT to produce any response (adjusted odds ratio 0.62, P < 0.0001). Rate of adjuvant chemotherapy usage was significantly lower after NACRT than after NAC (12% versus 34%, P < 0.0001). In patients with residual tumor and nodal disease, adjuvant chemotherapy was associated with higher OS after NACRT (adjusted hazard ratio 0.81, P = 0.05), but not after NAC. These results were further validated by propensity score analysis. CONCLUSIONS:NACRT had similar survival to NAC despite superior pathological downstaging. Adjuvant chemotherapy is relatively underused after NACRT and warrants further study as a risk-adapted means to improve survival, especially in patients with larger burden of residual disease.
Authors: Stephen G Swisher; Wayne Hofstetter; Ritsuko Komaki; Arlene M Correa; Jeremy Erasmus; Jeffrey H Lee; Zhongxing Liao; Dipen Maru; Reza Mehran; Shital Patel; David C Rice; Jack A Roth; Ara A Vaporciyan; Garrett L Walsh; Jaffer A Ajani Journal: Ann Thorac Surg Date: 2010-09 Impact factor: 4.330
Authors: Jaffer A Ajani; Kathryn Winter; Gordon S Okawara; John H Donohue; Peter W T Pisters; Christopher H Crane; John F Greskovich; P Rani Anne; Jeffrey D Bradley; Christopher Willett; Tyvin A Rich Journal: J Clin Oncol Date: 2006-08-20 Impact factor: 44.544
Authors: David Cunningham; William H Allum; Sally P Stenning; Jeremy N Thompson; Cornelis J H Van de Velde; Marianne Nicolson; J Howard Scarffe; Fiona J Lofts; Stephen J Falk; Timothy J Iveson; David B Smith; Ruth E Langley; Monica Verma; Simon Weeden; Yu Jo Chua Journal: N Engl J Med Date: 2006-07-06 Impact factor: 91.245
Authors: J V Reynolds; S R Preston; B O'Neill; L Baeksgaard; S M Griffin; C Mariette; S Cuffe; M Cunningham; T Crosby; I Parker; K Hofland; G Hanna; L B Svendsen; C L Donohoe; C Muldoon; D O'Toole; C Johnson; N Ravi; G Jones; A K Corkhill; M Illsley; J Mellor; K Lee; M Dib; V Marchesin; M Cunnane; K Scott; P Lawner; S Warren; S O'Reilly; G O'Dowd; G Leonard; B Hennessy; R Mc Dermott Journal: BMC Cancer Date: 2017-06-03 Impact factor: 4.430
Authors: Ali A Mokdad; Adam C Yopp; Patricio M Polanco; John C Mansour; Scott I Reznik; Daniel F Heitjan; Michael A Choti; Rebecca R Minter; Sam C Wang; Matthew R Porembka Journal: JAMA Oncol Date: 2018-01-01 Impact factor: 31.777
Authors: Astrid E Slagter; Edwin P M Jansen; Hanneke W M van Laarhoven; Johanna W van Sandick; Nicole C T van Grieken; Karolina Sikorska; Annemieke Cats; Pietje Muller-Timmermans; Maarten C C M Hulshof; Henk Boot; Maartje Los; Laurens V Beerepoot; Frank P J Peters; Geke A P Hospers; Boudewijn van Etten; Henk H Hartgrink; Mark I van Berge Henegouwen; Grard A P Nieuwenhuijzen; Richard van Hillegersberg; Donald L van der Peet; Heike I Grabsch; Marcel Verheij Journal: BMC Cancer Date: 2018-09-10 Impact factor: 4.430
Authors: Alexander P Stark; Mariela M Blum; Yi-Ju Chiang; Prajnan Das; Bruce D Minsky; Jeannelyn S Estrella; Jaffer A Ajani; Brian D Badgwell; Paul Mansfield; Naruhiko Ikoma Journal: J Gastric Cancer Date: 2020-09-17 Impact factor: 3.720
Authors: E L Vos; R A Carr; M Hsu; M Nakauchi; T Nobel; A Russo; A Barbetta; K S Tan; L Tang; D Ilson; G Y Ku; A J Wu; Y Y Janjigian; S S Yoon; M S Bains; D R Jones; D Coit; D Molena; V E Strong Journal: Br J Surg Date: 2021-11-11 Impact factor: 6.939