Buckstein M, Rhome R, Ru M, Moshier E
Departments of Radiation Oncology, Mount Sinai, New York, New York, USA.
Population Health Science and Policy, Icahn School of Medicine, Mount Sinai, New York, New York, USA.
Dis Esophagus. 2018 May 1;31(5). doi: 10.1093/dote/dox148.
Neoadjuvant chemoradiation (CRT) followed by surgical resection is the standard of care for resectable, locally advanced esophageal cancer. There are promising results using 41.4 Gy relative to historical controls using higher doses, but the utilization and efficacy of lower neoadjuvant radiation dosing is unclear. This study uses the National Cancer Database (NCDB) to explore patterns of care for neoadjuvant CRT dose levels and outcomes. The NCDB was queried for localized invasive esophageal adenocarcinoma (AC) or squamous cell carcinoma (SCC) receiving neoadjuvant CRT with doses from 40 to 54 Gy followed by surgical resection. Patients were divided into radiation levels: 40-41.4, 45, 50.4, and 54 Gy, respectively. Factors predicting use of 40-41.4 Gy vs. all other dose levels were compared using multivariable logistic regression. Factors affecting overall survival (OS) were compared using univariate and multivariate modeling. A total of 6,274 patients with AC (n = 5,176) or SCC (n = 1,098) receiving neoadjuvant CRT and definitive resection were identified. Hispanic race (OR 2.67 [95% CI 1.22-5.81]) and treatment at an academic center (OR 2.72 [95% CI 1.15-6.41]) predicted for use of low-dose CRT. Lower dose CRT increased from 3.9% in 2004 to 7.2% in 2013. There was no difference in OS when stratified according to radiation dose level (P = 0.48). Multivariable analysis found private/government insurance, higher education, higher median income, and treatment at an academic center were associated with improved OS. Age, male gender, Charlson-Deyo comorbidity score, stage, tumor grade, and treatment in the South were associated with worse OS. Use of lower neoadjuvant CRT dose is more common at academic centers and shows possible increasing usage. Neoadjuvant radiation dose for esophageal cancer is not associated with differences in OS in this large database.
新辅助放化疗（CRT）后行手术切除是可切除的局部晚期食管癌的标准治疗方法。与使用更高剂量的历史对照相比，使用41.4 Gy有令人鼓舞的结果，但较低新辅助放疗剂量的应用和疗效尚不清楚。本研究使用国家癌症数据库（NCDB）来探讨新辅助CRT剂量水平的治疗模式和结果。在NCDB中查询接受40至54 Gy新辅助CRT后行手术切除的局限性浸润性食管腺癌（AC）或鳞状细胞癌（SCC）。患者被分为放疗水平：分别为40 - 41.4、45、50.4和54 Gy。使用多变量逻辑回归比较预测使用40 - 41.4 Gy与所有其他剂量水平的因素。使用单变量和多变量模型比较影响总生存期（OS）的因素。共确定了6274例接受新辅助CRT和根治性切除的AC患者（n = 5176）或SCC患者（n = 1098）。西班牙裔种族（OR 2.67 [95% CI 1.22 - 5.81]）和在学术中心接受治疗（OR 2.72 [95% CI 1.15 - 6.41]）预测会使用低剂量CRT。低剂量CRT从2004年的3.9%增加到2013年的7.2%。根据放疗剂量水平分层时，OS没有差异（P = 0.48）。多变量分析发现，私人/政府保险、高等教育、较高的收入中位数和在学术中心接受治疗与OS改善相关。年龄、男性、Charlson - Deyo合并症评分、分期、肿瘤分级和在南方接受治疗与较差的OS相关。较低新辅助CRT剂量的使用在学术中心更为常见，且使用量可能在增加。在这个大型数据库中，食管癌的新辅助放疗剂量与OS差异无关。
