413P - Following planned pre-operative (pre-op) chemo-radiotherapy (CRT) for squamous cell cancer (SCC) of the esophagus (eso), why do some patients not undergo surgery (sx)? A service evaluation from a tertiary care hospital in a Low-Middle Income Country (LMIC

Background

Pre-op CRT followed by sx is the standard of care for resectable mid-lower third SCC of the eso. Neo-adjuvant chemotherapy (NACT) may precede pre-op CRT due to logistic reasons. In two randomized clinical trials reported from the developed countries, 7-10% patients did not proceed to sx after pre-op CRT. We report on patients not proceeding to sx in a consecutive patient cohort treated similarly as part of routine care.

Methods

Between Jan 2005 and Dec2019, 1400 patients of biopsy proven SCC of eso were seen and staged with CT scans of the thorax, abdomen and pelvis. PET scans were not used. Of these, 207, ≈ 15%, were considered potentially resectable by a multi-disciplinary tumor board and offered NACT (cisplatin (CDDP) 60-75mg/m² day 1 and capecitabine 1250 mg /m² day 1-21) for 1-2 cycles (cs), followed by preop CRT 45Gy / 25 fractions / 5 weeks with concurrent weekly CDDP 35-40mg/m² day 1, 8 15, 22, 29 to be followed by reassessment at 4 weeks and sx later. Those who did not proceed for surgery received further CRT to a total of 50.4Gy – 66.0 Gy at physician discretion.

Results

Out of 207 patients, 11 (5%), took no treatment. Of the remaining 196, 113 (58%) received NACT; 154 (79%) pre-op CRT. Of these 102 (52%) proceeded for sx with intended curative resections in 88 (86%), palliative resections in 2 (2%) and abandoned resections in12 (12%). Of the remaining 94 (48%), 15 (16%) refused sx; 17 (18%) progressed; 15 (16%) were medically inoperable; 9 (10%) were irresectable; 7 (7%) died on treatment; 14 (15%) had financial limitations and 17 (18%) were lost to follow up. Those operated were younger 54 v 58 years, p=0.002 and lower third more likely than middle third tumor location, p=0.039. With 85% events, and a potential followup of 9 years, the median overall survival (OS) was 24 months (mo) vs. 14 mo and the 5 year OS was 27% vs 16% respectively for those operated vs. not-operated, Log Rank p=0.001.

Conclusions

Following pre-op CRT for SCC eso, the widely disparate proportions of patients who go on to be resected successfully in an LMIC vs. a developed country are reflective of tumor bulk and socio-economic conditions.

Legal entity responsible for the study

The authors.

Funding

Has not received any funding.

Disclosure

All authors have declared no conflicts of interest.