Patients with complete clinical response after neoadjuvant chemoradiotherapy for locally advanced esophageal cancer: A Markov decision analysis of esophagectomy versus active surveillance

Objective Chemoradiation followed by esophagectomy is a standard treatment option for locally advanced esophageal cancer (LAEC) patients. Esophagectomy is a high-risk procedure, and recent evidence suggests select patients may benefit from omitting or delaying surgery. This study aims to compare surgery versus active surveillance for LAEC patients with complete clinical response (cCR) after neoadjuvant chemoradiotherapy (nCRT). Methods Decision analysis with Markov modelling was utilized. The base case was a 60-year-old male with T3N0M0 esophageal cancer with cCR after nCRT. The decision was modelled for a 5-year time horizon. Primary outcomes were life-years (LY) and quality-adjusted life-years (QALYs). Probabilities and utilities were derived through literature. Deterministic sensitivity analyses were performed using ranges from literature with consideration for clinical plausibility. Results Surgery was favoured for survival with an expected LY of 2.89 versus 2.64. After incorporating quality of life, active surveillance was favoured with an expected QALY of 1.70 versus 1.56. The model was sensitive to probability of recurrence on active surveillance (threshold value 0.598), probability of recurrence being resectable (0.318) and disutility of prior esophagectomy (-0.091). The model was not sensitive to perioperative morbidity and mortality. Conclusions Our study finds that surgery increases life expectancy but decreases quality-adjusted life years. Although the incremental change in QALY for either modality is insufficient to make broad clinical recommendations, our study demonstrates that either approach is acceptable. As probabilities of key factors are further defined in the literature, treatment decisions for patients with LAEC and a cCR after nCRT should consider histology, patient values, and quality of life.