Comparison of Postoperative Esophagectomy Outcomes in Esophageal Cancer Patients Receiving Preoperative Radiotherapy at an Academic Medical Center vs. Community Medical Centers.

Abstract

PURPOSE/OBJECTIVE(S)\nTreatment for locally-advanced esophageal cancer commonly involves upfront radiotherapy and chemotherapy prior to surgery. Esophagectomy is a complex oncologic procedure that results in lower perioperative morbidity and mortality when performed in high-volume hospitals by experienced surgeons. Radiotherapy is a critical component of management and can lead to both acute and chronic local toxicity that directly impacts risk of surgical complications. Limited data exists evaluating the importance of radiation delivery at high vs low volume centers. We sought to compare postoperative toxicity amongst patients treated with preoperative radiotherapy delivered at an academic medical center (AMC) versus community medical centers (CMC).\n\n\nMATERIALS/METHODS\nConsecutive patients undergoing esophagectomy for locally-advanced esophageal or gastroesophageal junction (GEJ) cancer at an academic medical center between 2008 and 2018 were reviewed. Patients treated for stage IVB or recurrence were excluded as were patients with incomplete treatment details. All patients were treated with intensity modulated radiation therapy (IMRT) or 3D conformal radiation therapy (3D CRT). Rural-Urban Continuum Codes were assigned to patients residential addresses. Differences between groups were compared using chi-squared or t-tests.\n\n\nRESULTS\n148 consecutive patients were identified: 89 CMC and 59 AMC. Median follow up was 30 months (0.33-124 months). Most patients were male (85.8%) with adenocarcinoma (90%) located in the distal esophagus or GEJ (95%). Distance between residential address and surgery center differed between groups (78 miles CMC vs 41 miles AMC, P < 0.01) with a trend towards more rural patients from CMCs (28% vs 15%, P\u202f=\u202f0.07). AMC patients consisted of more women (25.4% vs 6.7%, P < 0.01) otherwise groups were balanced. The median time to surgery in CMC was 51 days and 49 days for AMC. Median radiation dose was 50.4 Gy (39.6 - 61.2 Gy) for CMC and 50.4 Gy (41.4 - 56 Gy) for AMC (P\u202f=\u202f0.60). IMRT was more commonly used in CMCs than AMCs (66% vs 41%, P < 0.01). No difference between AMC and CMC was observed when comparing length of hospitalization, 90-day readmission rate, or wound, pulmonary or cardiac complications. Radiotherapy at CMCs required higher rates of re-operation after esophagectomy (19% vs 7%, P\u202f=\u202f0.03). Anastomotic leak occurred in 38% CMC patients compared to 17% AMC patients (P < 0.01). Overall anastomotic stenosis rates were higher among CMC patients compared to AMC (35% vs 16%, P\u202f=\u202f0.01) with a median time to stenosis of 2.8 months.\n\n\nCONCLUSION\nEsophageal cancer patients receiving preoperative radiotherapy had higher rates of postoperative toxicity when radiotherapy was completed at a community medical center versus academic medical center. Explanations for these differences are uncertain but further exploratory analyses regarding dosimetry and radiation field size are warranted.