By Megan Brooks
NEW YORK (Reuters Health) - Patients with esophageal cancer who opt out of surgery when it is recommended may not live as long as their peers who have surgery, according to research presented January 30 at the Society of Thoracic Surgeons annual meeting.
“Although it may be tempting for patients to opt for nonsurgical treatment for cardiothoracic diseases in order to avoid the perceived pain and complications of surgery, this choice may come with a price,” lead author Dr. Brendon Stiles of Weill Cornell Medicine in New York City said in a news release.
“In our study, we show that even if patients recommended for surgery elect to pursue other treatments, they do more poorly than if they had included surgery as part of their treatment,” he noted.
Using the National Cancer Database, the Weill Cornell team identified 12,298 patients with esophageal cancer including 708 (6%) patients who were advised to have surgery but declined, opting instead for definitive chemoradiation (41%), sequential chemotherapy/radiation (36%), radiation and/or chemotherapy alone (8%), or to forgo any treatment (15%).
Overall, patients who had surgery lived longer than those who did not (median, 35.6 vs. 24.8 months).
Likewise, in a propensity-matched analysis comparing 525 patients who refused surgery with 525 patients who had preoperative therapy followed by surgery, patients who had surgery survived longer than those who did not (median survival, 32.3 vs. 21.9 months). In a multivariate analysis, refusal of surgery remained a strong predictor of poorer survival (odds ratio, 1.72; P<0.001).
“The difference in survival between patients who had surgery and those who were offered but refused was striking,” Dr. Stiles said in the release.
Patients with earlier-stage (I and II) tumors were more likely to refuse surgery, as were older, non-white women.
“We have been very concerned by the increased rates of cancer patients opting for nonsurgical therapies despite the absence of long-term survival data,” said Dr. Stiles. “While all of the nonsurgical techniques seem easier and less invasive to patients in the short term, patients should understand the long-term implications.”
“Discussions regarding long-term survival and not just short-term outcomes should be a major part of any shared decision-making process, and we certainly feel that thoracic surgeons should be involved in that discussion,” Weill Cornell's Dr. Sebron Harrison said during a media briefing, where he presented the study results.
Briefing moderator Dr. Mark Allen of Mayo Clinic in Rochester, Minnesota, said this study is “very well done” and helps answer a “very important question.”
Often after chemoradiation, he explained, “there is no evidence of any residual cancer, and then you have to have a discussion with the patient about whether it is worthwhile to go through an operation to try to increase the cure rate. Now, with this study, I can tell my patients that there is about a 20% increase (in chance of cure) by having an operation.”
Society of Thoracic Surgeons 2018.
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