| Background and ObjectiveEsophageal cancer is one of the most common malignant gastrointestinal tumors in China,and its incidence ranks the fifth among women,second only to breast cancer,lung cancer,gastric cancer and colon cancer,and third among men,second only to lung cancer and gastric cancer.In recent years,the incidence rate and mortality of esophageal cancer have been reduced with the rapid development of esophageal cancer diagnosis,treatment and prevention technology.However,the number of Chinese esophageal cancer patients is still the largest in the world,which accounts for about one half of the global esophageal cancer patients.In the past,Esophagectomy is the best traditional treatment for esophageal cancer,but it can easily cause a high level of complication---as high as about 20% to 50%---whose mortality rate is up to 10%.With the use of modern precise radiotherapy and chemotherapy combined with surgery,the prognosis of many the patients has been improved.However,the prognosis of esophageal cancer patients is not optimistic in the world.The 5-year survival rate is only about 20%.The biggest reason is that the early symptoms of esophageal cancer are relatively mild.About 90% of patients with esophageal cancer are already in the advanced stage of treatment.Therefore,early diagnosis and treatment of esophageal cancer still have a long way to go.In recent years,endoscopic diagnosis and treatment technology has made rapid progress.In addition,Chinese people are increasingly alert to diseases,and patients with early esophageal cancer in China are on the rise.Early esophageal cancer refers to that the tumor is confined to the mucosa without lymph node metastasis,and then divided into T1a(mucosal lamina propria or mucosal muscularis)and T1b(submucosa)according to the depth of infiltration.The choice of treatment for esophageal cancer mainly depends on the depth of tumor invasion and local lymph node metastasis.For superficial and early esophageal cancer with low lymph node metastasis rate,endoscopic treatment is also an appropriate treatment method in addition to traditional esophagectomy.The lymph node metastasis rate of stage T1 a esophageal cancer is only about 3%,So currently,the endoscopic treatment which has a higher priority than esophagectomy because of its little trauma to patients and little effect to their quality of life is recognized as a safe and effective treatment for this stage of esophageal cancer.T1 b esophageal cancer lymph node metastasis rate is high,and with the increase of infiltration depth,it’s believed that the best treatment for surgical treatment.However,some other experts believe that we can select T1 b esophageal cancer patients who are suitable for endoscopic treatment by establishing the risk model with the length of the tumor,differentiation and infiltration depth when their tumor length less than 2 cm of T1 b esophageal cancer lymph node metastasis rate of about 8%.The recent national comprehensive cancer network(NCCN)recommends surgical and endoscopic treatment for T1 a and esophagectomy for T1 b esophageal cancer.Currently,the selection of treatment methods for early esophageal cancer is not uniform,which is still a research hotspot.For elderly patients with early esophageal cancer(aged over 75 years)with more restrictions,the selection of treatment methods should be more individualized.This study retrospectively analyzed the long-term survival differences of elderly patients with stage cT1N0M0 esophageal cancer receiving esophagectomy,endoscopic treatment and radiotherapy through a large sample size,aiming to provide sufficient clinical basis for the individualized treatment of elderly patients with early esophageal cancer.MethodsThe Surveillance,Epidemiology,and End Results(SEER)database was queried to identify elderly patients(≥75 years)with cT1N0M0 esophageal cancer between 2004 and 2014.Patient demographics and esophageal cancer parameters were compared among ES(Esophagectomy),ET(Endoscopic therapy)and RT(Radiotherapy)groups.The related parameters in the extraction and tumor patients using χ2 test and T test are compared,and analysis of the life table survival analysis method to calculate the 5-year overall survival rate(OS)and cancer-specific survival(CSS),the Kaplan-Meier survival curve drawing method,application of the prognosis of patients with COX proportional hazards model analysis influencing factors.Then the three groups were matched by pairwise 1:1 propensity score,and the above statistical methods were used for further analysis and comparison.Results1.Data from 954 esophageal cancer patients(ES: n = 196,20.5%;ET: n = 224,23.5%;RT: n = 534,56%)were included.There was an increase in the proportion of patients who underwent ET from the year of diagnosis 2004-2009(19.1%)to 2010-2014(30.1%),while RT decreased from 60.5 to 49.2%(P<0.05),and ES remained relatively stable(20.5 vs.20.7%).There was also an increase in 5-year OS(24.1 vs.28%,P = 0.005)and CSS(42.9 vs.53.2%,P = 0.02)from 2004-2009 to 2010-2014.2.The 5-year OS of ES,ET and RT groups were 50.5%,39.6% and 12.1%(P < 0.001),while CSS were 70.3%,72.2% and 24.7%(P < 0.001).The 5-year OS after ET and ES was not significantly different(50.5% vs 39.6%,P=0.387);5-year CSS(70.3% vs 72.2%,P=0.324)also did not differ.Multivariate Cox regression analysis showed that 5-year OS(ET HR: 0.37,95%CI [0.29-0.47],P<0.001;ES HR: 0.31,95%CI [0.23-0.41],P<0.001)and CSS(ET HR: 0.21,95%[0.15-0.30],P<0.001;ES HR: 0.25,95%[0.17-0.37],P<0.001)of ET and ES groups were significantly higher than those of RT group,but esophageal cancer patients who underwent ES did not improve 5-year OS(HR: 0.82,95%CI [0.60-1.13],P=0.22)or CSS(HR: 1.15,95%CI [0.72-1.84],P=0.55)compared with those who underwent ET.3.There were 70 pairs of patients in endoscopic treatment group and esophagectomy group by propensity score matching.The analysis showed that there were no significant differences in 5-year OS(46.7% vs 50.4%,P=0.64)and 5-year CSS(70.6% vs 66.9%,P=0.963)between ET group and ES group.Multivariate COX regression analysis showed that esophagectomy did not improve 5-year OS(HR: 0.756,95%CI [0.491-1.366],P=0.35)and CSS(HR: 0.89,95%CI [0.394-2.013],P=0.78)compared with endoscopic treatment.4.There were 105 pairs of patients in Endoscopy Group and radiotherapy group by propensity score matching.Posterior analysis showed that the 5-year OS(38.9% vs 16.1%,P < 0.001)and 5-year CSS(68.3% vs 25.5%,P < 0.001)in the ET group were significantly higher than those in the RT group.Multivariate COX regression analysis showed that endoscopy significantly improved 5-year OS(HR: 0.36,95% CI [0.24-0.52],P < 0.001)and CS(HR: 0.20,95% CI [0.12-0.34],P < 0.001)compared with radiotherapy.5.There were 82 pairs of patients in the esophagectomy group and the radiotherapy group by propensity score matching.The analysis showed that the 5-year OS(52.2% vs 21.5%,P < 0.001)and CSS(70.0% vs 38.4%,P < 0.001)in the ES group were significantly higher than those in the RT group.Multivariate COX regression analysis showed that esophagectomy significantly improved OS(HR: 0.26,95% CI [0.13-0.50],P < 0.001)and CSS(HR: 0.16,95% CI [0.05-0.41],P < 0.001)for 5 years compared with radiotherapy.ConclusionsUsing SEER data,we have identified a significant survival advantage with the use of ES and ET compared with RT in patients older than 75 years with cT1N0M0 esophageal cancer,while the long-term survival of patients after ET and ES was not significantly different.Our findings strongly support the use of ET for elderly patients with early esophageal cancer. |
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