Margin Positivity in Resectable Esophageal Cancer: Are there Modifiable Risk Factors?
Patients with esophageal cancer have poor overall survival, with positive resection margins worsening survival. Margin positivity rates are used as quality measures in other malignancies, but modifiable risk factors are necessary to develop actionable targets for improvement. Our objectives were to (1) evaluate trends in esophageal cancer margin positivity, and (2) identify modifiable patient/hospital factors associated with margin positivity.
Patients who underwent esophagectomy from 2004 to 2015 were identified from the National Cancer Database. Trends in margin positivity by time and hospital volume were evaluated using Cochrane–Armitage tests. Associations between patient/hospital factors and margin positivity were assessed by multivariable logistic regression.
Among 29,706 patients who underwent esophagectomy for cancer, 9.37% had positive margins. Margin positivity rates decreased over time (10.62% in 2004 to 8.61% in 2015; p < 0.001). Older patients (≥ 75 years) were more likely to have positive margins [odds ratio (OR) 2.04, 95% confidence interval (CI) 1.42–2.92], as were patients with a Charlson–Deyo Index ≥ 3 (OR 1.84, 95% CI 1.08–3.12). Patients who received neoadjuvant therapy were less likely to have positive margins (OR 0.37, 95% CI 0.29–0.47), while laparoscopic surgical approach was associated with increased margin positivity (OR 1.70, 95% CI 1.40–2.06). As the hospital annual esophagectomy volume increased, margin positivity rates decreased (7.76% in the fourth quartile vs. 11.39% in the first quartile; OR 0.70, 95% CI 0.49–0.99).
Use of neoadjuvant therapy, surgical approach, and hospital volume are modifiable risk factors for margin positivity in esophageal cancer. These factors should be considered in treatment planning, and margin positivity rates could be considered as a quality measure in esophageal cancer.
This study was supported by the Northwestern Institute for Comparative Effectiveness Research in Oncology (NICER-Onc) of the Robert H. Lurie Comprehensive Cancer Center. RK is supported by a postdoctoral research fellowship from the National Heart, Lung, and Blood Institute (5T32HL094293); DDO is supported by the National Cancer Institute (K07CA216330); RPM is supported by the Agency for Healthcare Research and Quality (K12HS026385) and an Institutional Research Grant from the American Cancer Society (IRG-18-163-24); and DJB is supported by a Veteran’s Administration Merit Award (I01HX002290).
Cary Jo R. Schlick, Rhami Khorfan, David D. Odell, Ryan P. Merkow, and David J. Bentrem report no conflicts of interest, financial or otherwise, related to this work. The NCDB is a joint project of the CoC of the American College of Surgeons and the American Cancer Society. The CoC’s NCDB and the hospitals participating in the CoC NCDB are the source of the de-identified data used herein. They have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
- 44.Wei D, Johnston S, Goldstein L, Nagle D. Minimally invasive colectomy is associated with reduced risk of anastomotic leak and other major perioperative complications and reduced hospital resource utilization as compared with open surgery: a retrospective population-based study of comparative effectiveness and trends of surgical approach. Surg Endosc. 2019; https://doi.org/10.1007/s00464-019-06805-y.CrossRefPubMedGoogle Scholar
- 48.The Leapfrog Group Surgical Volume. Available at: https://www.leapfroggroup.org/ratings-reports/surgical-volume. Accessed June 2019.