Longitudinal Follow-up of Medicare Patients After Esophageal Cancer Resection in the STS Database

Abstract

Background: Understanding characteristics associated with survival after esophagectomy for cancer is critical to preoperative risk stratification. This study sought to define predictors for long-term survival after esophagectomy for cancer in Medicare patients. Methods: The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for patients aged ≥65 years who underwent esophagectomy for cancer between 2012 and 2020 and linked to Centers for Medicare and Medicaid Services (CMS) data using a deterministic matching algorithm. Patient, hospital, and treatment variables were assessed using a multivariable Cox proportional hazards model to evaluate characteristics associated with long-term mortality and readmission. Kaplan-Meier and cumulative incidence curves were generated and differences evaluated using the log-rank test and Gray's test, respectively. Results: After CMS linkage, 4798 patients were included. Thirty-day and 90-day mortality in the study group was 3.84% and 7.45%, respectively. In the multivariable model, American Society of Anesthesiologists score >3, body mass index >35, and diabetes were associated with increased mortality <90 days post-surgery, while pN/pT upstaging was associated with increased mortality >90 days post-surgery. Patients upstaged to pN(+) had a 147% increased mortality risk (adjusted hazard ratio [aHR], 2.47; 95% CI, 2.02-3.02) and those that remained pN(+) a 75% increased mortality risk (aHR, 1.75; 95% CI, 1.57-1.95) compared with downstaged patients. Patients who were pT upstaged had a 109% (aHR, 2.09; 95% CI, 1.73-2.53) increased mortality risk compared with pT downstaged patients. Risk for readmission was independent of procedure type or approach and was higher in c stage ≥2, American Society of Anesthesiologists score ≥4, and pN+. Conclusions: Medicare patients undergoing esophagectomy for cancer have identifiable patient-specific predictors for short-term mortality and tumor-specific predictors for long-term mortality and readmission. In the absence of pathologic T and N downstaging, risk for long-term mortality and readmission are increased.