Patterns of Care in Neoadjuvant Chemoradiotherapy for Node-Positive Esophageal Adenocarcinoma

Background. The aims of this study were to examine the factors associated with use of neoadjuvant chemoradiotherapy (NCR) for patients with locally advanced esophageal cancer and to evaluate the effect of NCR on survival.Methods. The 2004 to 2015 National Cancer Database was used to identify patients with cT1-4aN1-3M0 (stage II-IVA) esophageal adenocarcinoma who underwent esophagectomy. Patients were stratified by receipt of NCR. A multivariable logistic regressionwas performed to examine factors associated with NCR, and survival between the 2 groups was compared using a multivariable Cox model.Results. Of 8076 patients meeting the study criteria, 1616 (20%) did not receive NCR and 6460 (80%) did. In a multivariable regression, factors associated with receipt of NCR were a later year of diagnosis, treatment in a high-volume center, and clinical stage III disease. Factors associated with nonreceipt of NCR were increasing age, comorbidities, and treatment in a Middle Atlantic, South Central, or Pacific state. Receipt of trimodality therapy was associated with improved survival compared with other or no perioperative therapies (adjusted hazard ratio, 0.80; 95% confidence interval, 0.74-0.87).Conclusions. Numerous personal-, demographic-, and treatment center-related factors account for variability in NCR for clinically node-positive esophageal adenocarcinoma, although neoadjuvant therapy was associated with a survival benefit. Further efforts are needed to identify reasons for these differences and design interventions to provide more equitable care for patients with esophageal cancer. (C) 2020 by The Society of Thoracic Surgeons