TOPLINE:

A decision analysis model found that over 5 years, patients who were complete responders to chemoradiation stood to gain more quality-adjusted life years (QALYs) with standard surgery than with active surveillance.

METHODOLOGY:

• Active surveillance with salvage surgery has been proposed as an alternative to esophagectomy for patients who have a clinical complete response after neoadjuvant chemoradiation. The SANO trial found that 2-year survival was non-inferior with active surveillance vs standard esophagectomy, while short-term quality of life was better. However, it also raised concerns, including the risk for advanced disease in patients needing salvage surgery.
• To help clinicians interpret the SANO findings in context, researchers constructed a decision-analysis Markov model using published probabilities and utilities to compare standard surgery with active surveillance in patients with locally advanced esophageal cancer.
• The analysis included a base case of a 60-year-old man with good functional status and cT3N1M0 esophageal cancer who achieved a complete clinical response after chemoradiation.
• Model parameters were derived from the SANO trial and a comprehensive literature review and included surgical mortality, morbidity, recurrence probabilities and patterns, and quality-of-life outcomes. The study estimated 5-year QALYs, with LYs as a secondary measure of survival.

TAKEAWAY:

• At 5 years, standard surgery yielded better outcomes than active surveillance in terms of QALYs and LYs — 1.74 vs 1.34 QALYs (incremental gain, 0.40 QALYs) and 3.11 vs 2.41 LYs (incremental gain, 0.70 LYs).
• Overall, the model favored active surveillance when the probability of recurrence was less than 43%. (For context, that probability was 65% in the SANO trial.) Active surveillance was also preferred when the likelihood of local or resectable recurrence was greater than 94% (it was 48% in SANO), or when esophagectomy was likely to substantially decrease a patient’s quality of life.
• In time-varying models where quality-of-life effects resolved after 6, 9, or 12 months, surgery was consistently favored, yielding incremental QALY gains of 5.4, 5.0, and 4.8 months, respectively.
• In a model exploring QALYs at 2 years, active surveillance was favored, with an expected benefit of 15 days in perfect health. However, when exploring survival at 2 years, standard surgery was superior to surveillance, with an expected benefit of 40 days.

IN PRACTICE:

“Standard surgery is preferred in most clinical scenarios, with active surveillance being preferred when surgical morbidity or mortality is exceptionally high or the probability of recurrence is exceptionally low,” the authors of the study wrote. “Active surveillance may be reasonable for select patients but should not be viewed as standard of care.”

SOURCE:

The study, led by Adom Bondzi-Simpson, MD, MSc, University of Toronto, Toronto, Ontario, Canada, was published online in JAMA Surgery.

LIMITATIONS:

Because model probabilities and utilities were derived from a comprehensive literature review, estimates may have been affected by publication bias and may not perfectly represent current population values. The model did not capture changes in risk over time or account for the quality-of-life impact of repeated visits and endoscopy with active surveillance.

DISCLOSURES:

The authors did not disclose any funding information. Some authors reported receiving grants or speaking honoraria and having other ties with various sources. Full disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.