Utilization Trends and Volume-outcomes Relationship of Endoscopic Resection for Early Stage Esophageal Cancer

Abstract

Objectives: We describe utilization trends and center volume-outcomes relationship of ER of early stage esophageal cancer using a large hospitalbased registry. Summary of Background Data: ER is increasingly accepted as the preferred treatment for early stage esophageal cancer, however its utilization and the center volume-outcomes relationship in the United States is unknown. Methods: The National Cancer Database was used to identify patients with cT1N0M0 esophageal cancer treated with ER or esophagectomy between 2004 and 2015. Relative frequencies were plotted over time.Restricted cubic splines and maximally selected rank statistics were used to identify an inflection point of center volume and survival. Results: A total of 1136 patients underwent ER and 2829 patients underwent esophagectomy during the study period. Overall utilization of ER, and relative use compared to esophagectomy, increased throughout the study period. Median annualized center ER volume was 1.9 cases per year (interquartile range 0.5-5.8). Multivariable Cox regression showed increasing annualized center volume by 1 case per year was associated with improved survival. Postoperative 30-or 90-day mortality, 30-day readmission, and pathologic T upstaging rates were similar irrespective of center volume. Conclusions: Utilization of ER compared to esophagectomy for stage I esophageal cancer has increased over the past decade, though many individual centers perform fewer than 1 case annually. increasing annualized center volume by one procedure per year was associated with improved survival. increased volume beyond this was not associated with survival benefit. Referral to higher volume centers for treatment of superficial esophageal cancer should be considered.

The Effect of Center Esophagectomy Volume on Outcomes in Clinical Stage I to III Esophageal Cancer

“…29 In addition, our group has previously utilized restricted cubic splines in regression analysis to study volume-outcomes in endoscopic resection, threshold tumor sizes for treatment options in non-small cell lung cancer, lymph node ratios for adjuvant therapy decision-making, and optimal time to surgery in esophageal cancer. [30][31][32][33][34] Restricted cubic splines can be a powerful tool for analysis of continuous predictor variables on outcomes, particularly when a complex nonlinear relationship exists. 20,35 Simple categorization of such variables into quartiles or quintiles can miss important relationships.…”

Value of EUS in determining infiltration depth of early carcinoma and associated precancerous lesions in the upper gastrointestinal tract

“…For early tumors, the main treatments include endoscopic mucosal resection, endoscopic submucosal dissection (ESD), and surgery. [ 4 5 6 ] Compared with surgery, endoscopy has the advantages of less trauma, a higher cure rate, and faster recovery. [ 7 8 ] However, the selection of treatment is based on the invasion depth and lymph node and distant metastases.…”