A multi-Institutional analysis of trimodality therapy for esophagus cancer in elderly patients

Publication date: Available online 20 February 2017
Source:International Journal of Radiation Oncology*Biology*Physics
Author(s): Scott C. Lester, Steven H. Lin, Michael Chuong, Neha Bhooshan, Zhongxing Liao, Sarah E. James, Jaden D. Evans, Grant M. Spears, Ritsuko Komaki, Michael G. Haddock, Minesh P. Mehta, Christopher L. Hallemeier, Kenneth W. Merrell
PurposeThe therapeutic gains of neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy may be offset by increased incidences of morbidity and mortality in elderly patients. This study aimed to determine the impact of age on the risks and benefits of trimodality therapy for esophagus cancer.Methods and MaterialsWe evaluated 571 patients treated with trimodality therapy at 3 high-volume tertiary U.S. cancer centers from 2007 to 2013. 202 of 571 (35%) patients were 65 years or older at diagnosis and were classified as elderly. Toxicity and treatment parameters for the elderly cohort were compared with the younger cohort (ages 22-64) using univariate (UVA) and multivariable (MVA) logistic analyses. Age was analyzed as a continuous hazard for cardiac and pulmonary toxicities. Survival was assessed using the Kaplan-Meier method.ResultsElderly patients had a higher risk for postoperative cardiac (UVA: OR 2.2, p<0.001; MVA: OR 2.07, p=0.004) and pulmonary toxicities (UVA: OR 2.0, p<0.001; MVA: OR 2.03, p<0.001), and a higher 90-day postoperative mortality (5.4 vs 2.2%, p=0.049). 6.9% of the elderly experienced acute respiratory distress syndrome compared to 3.8% of younger patients (p=0.11). Cardiac toxicity was linearly associated with age and the relative risk increased by 61% for every additional decade of age. There was no difference in postoperative gastrointestinal or wound complications, or length of hospital stay. Grade 3+ acute toxicities from nCRT were infrequent and clinically similar regardless of age. Freedom from esophagus cancer and disease free survival were similar, but overall survival was significantly shorter in the elderly cohort.ConclusionsElderly patients experienced more postoperative cardiopulmonary toxicities and mortality than younger patients after neoadjuvant chemoradiotherapy. Compared with contemporary outcomes for trimodality therapy, both cohorts had acceptable rates for adverse events and disease control. For appropriately selected elderly patients, trimodality therapy for esophagus cancer is a reasonable treatment option.

Teaser

The therapeutic ratio for esophagectomy following chemoradiotherapy for elderly patients is not clear. In this analysis of 202 elderly patients treated with trimodality therapy at 3 high volume cancer centers rates of cardiopulmonary toxicity and postoperative death were increased compared with a younger cohort. Despite relative increases in morbidity and mortality, absolute incidences of toxicity and death were within reported contemporary standards and disease free survival was not significantly impacted by age.


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