Elsevier

The Lancet Oncology

Volume 6, Issue 11, November 2005, Pages 864-870
The Lancet Oncology

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Survival after surgery for oesophageal cancer: a population-based study

https://doi.org/10.1016/S1470-2045(05)70347-8Get rights and content

Summary

Background

Oesophageal resection alone remains the only potentially curative treatment for oesophageal cancer. However, few population-based studies of survival after surgery have been done. We aimed to assess whether survival after surgery for oesophageal cancer has improved since 1987.

Methods

We identified from the nationwide cancer register 764 patients in Sweden who had undergone resection alone for oesophageal cancer between Jan 1, 1987 and Dec 31, 2000, and followed up these individuals until Oct 18, 2004, through linkage to the nationwide registers of death, emigration, and total population. Tumour stage, location, and histology were recorded by review of histopathological reports. Hazard ratios, with 95% CI, for death adjusted for age; sex; comorbidity; and tumour stage, location, and histology were calculated by Cox proportional-hazards regression model.

Findings

Overall, the proportion of deaths up to 30 days after surgery decreased from 10·1% in 1987–91 to 4·9% in 1997–2000. Increased long-term survival was associated with low tumour stage. Survival was 46·5% 1 year after surgery, 24·1% 3 years after surgery, and 19·7% 5 years after surgery in 1987–91; 58·4%, 31·7%, and 24·9%, respectively, in 1992–96; and 61·7%, 39·9%, and 30·7%, respectively, in 1997–2000. The adjusted hazard ratio for death was 0·76 (95% CI 0·62–0·92) in 1992–96 and 0·57 (0·45–0·71) in 1997–2000.

Interpretation

Survival after surgery for oesophageal cancer has improved substantially since 1987. Because this improvement cannot be explained by a change in patient characteristics or tumour characteristics, it is probably a result of better surgery.

Introduction

Oesophageal cancer is the eighth most common cancer worldwide.1 During the past three decades, the incidence of oesophageal adenocarcinoma has increased rapidly in most developed countries, whereas that of squamous-cell carcinoma has been more stable.2, 3, 4 Patients with either histological type have a poor outlook (ie, overall 5-year survival of 10% or less in Europe).5 However, some studies have shown improved survival during recent years, including one from Sweden.6 Tumour stage is the strongest known prognostic factor of survival.7 Furthermore, because most randomised trials8, 9, 10, 11 have not shown a long-term survival advantage for adjuvant chemoradiotherapy, surgical resection alone remains the only potentially curative treatment for patients with oesophageal cancer.12, 13 Studies done at one institution suggest that surgery offers a 25–35% chance of cure and that survival has improved rates in recent years;13, 14 however potential selection bias hinders interpretation of these reports.

Few population-based studies that assess the effect of tumour stage on survival have been done. Therefore, survival after surgery for oesophageal cancer surgery in a population-based setting remains unknown, and any apparent improvement with time is uncertain. We aimed to do a population-based study to assess short-term and long-term outlook after surgery (ie, resection) for oesophageal cancer in Sweden, with complete follow-up and access to all relevant potential confounding factors. We postulated that survival after surgery for oesophageal cancer has improved since 1987 because of improved surgical quality.

Section snippets

Study design

Patients with oesophageal cancer were identified through the Swedish cancer register by employees at the registry. Surgical procedures (including the type of surgery, date of surgery, and hospital where the operation was done) and comorbidities were assessed by employees at the Swedish Board of Health and Welfare using the Swedish inpatient register. Tumour stage, location, and histological type were verified by IR, who reviewed histopathological records of the resected tumours. To obtain

Results

From the cancer register, we identified 4904 patients who were diagnosed with oesophageal cancer between 1987 and 2000, 1199 (24%) of whom had surgical resection. After exclusion of 391 (33%) patients who had received preoperative treatment for cancer and 44 (4%) patients with missing data, 764 (64%) patients who had had oesophageal resection alone remained for analysis. Histopathological records were obtained for 750 (98%) patients; tumour stage for 14 patients with missing histopathological

Discussion

We have shown that short-term and long-term survival after surgery for oesophageal cancer in Sweden has improved since 1987.

The complete nationwide and population-based design, which included all patients with oesophageal cancer treated with surgery, was an advantage of our study. Such a design importantly counteracts selection bias and ensures generalisability of the findings. The complete follow-up, length of observation, uniform staging of tumours according to modern standards, access to

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