Gastrointestinal Cancer

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SU_8_2074 - Adherence and Reasons for Non-Adherence to a Tri-Modality Regimen in the Treatment of Esophageal Cancer

Sunday, October 21
1:15 PM - 2:45 PM
Location: Innovation Hub, Exhibit Hall 3

Adherence and Reasons for Non-Adherence to a Tri-Modality Regimen in the Treatment of Esophageal Cancer
D. Koffler1, R. Rahmani2, K. Haisley2, J. Hunter2, J. M. Holland2, C. R. Thomas Jr2, J. Dolan2, and N. Nabavizadeh2; 1SUNY Downstate College of Medicine, Brooklyn, NY, 2Oregon Health and Science University, Portland, OR

Purpose/Objective(s): In locally-advanced esophageal cancer, providers' doubts regarding eventual surgical candidacy can affect radiation prescriptions, with many deferring to definitive doses of 50.4 Gy or higher in the preoperative setting. We report the successful completion rate of tri-modality therapy (TMT) and reasons for non-adherence to TMT in patients treated at a large multi-disciplinary esophageal program.

Materials/Methods: We identified locally-advanced esophageal cancer patients diagnosed between 2007 and 2016 from a prospective institutional database. Patients indicated for TMT (documentation of planned TMT at the outset) were divided into a CRT/S+ group (documentation of completed surgery) and a CRT/S- group (completion of CRT and no subsequent surgery). Detailed chart review provided reasons for non-adherence to TMT.

Results: Two-hundred eighty-three patients with documentation of planned TMT prior to CRT were identified. CRT consisted of doses of 50 or 50.4 Gy for 164 patients (57.9%), greater than 50.4 Gy for 27 patients (9.5%) and less than 50 Gy for 92 patients (32.5%, only 8 patients received RT to 41.4 Gy). Concurrent chemotherapy largely consisted of cisplatin/5FU (predominating pre-CROSS trial therapy) or carboplatin/paclitaxel (post-CROSS therapy). Of the TMT-indicated patients, 221 (78.0%) completed surgery after CRT (CRT/S+), while 62 (22.0%) failed to advance to surgery (CRT/S-). Of the 62 CRT/S- patients, 25 (40.3%) had evidence of metastatic progression following CRT (20 identified on imaging, 5 identified intraoperatively), 4 (6.5%) were unresectable intraoperatively, 4 (6.5%) expired prior to planned surgery (3 from unknown causes, 1 committed suicide), 8 (12.9%) experienced significant medical decompensation from CRT and were no longer surgical candidates, 16 (25.8%) voluntarily declined surgery following CRT (largely due to the concerns of long-term quality of life) and 5 (8.1%) failed to advance to surgery for unknown reasons. Four of the 16 patients who voluntarily declined surgery after CRT received RT doses of less than 50 Gy. For the CRT/S+ patients, the pathologic complete response rate was 22.2% (21.6% for adenocarcinoma and 29.0% for squamous cell carcinoma). For the 138 patients with residual disease on pathology, 128 (92.7%) had no tumor at the resection margins (R0).

Conclusion: At our institution, a 78% rate of success in completing surgery among patients indicated for TMT highlights the benefits of upfront multi-disciplinary care. As over 25% of our CRT/S- patients declined esophagectomy voluntarily, thorough surgical counseling prior to CRT is essential to avoid under-treatment. For our CRT/S+ patients, pCR and R0 resection rates did not quantitatively improve over the published CROSS trial. In the absence of a demonstration of superiority of radiation doses greater than 41.4 Gy, the robust CROSS regimen should be the standard of care in managing esophageal TMT patients, especially if evaluated upfront in a multi-disciplinary setting.

Author Disclosure: D. Koffler: None. J. Hunter: None. J.M. Holland: None. C.R. Thomas: None. J. Dolan: None. N. Nabavizadeh: None.

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