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OBJECTIVE: This population-based study aimed to compare presentation, treatment allocation and survival of potentially curable esophageal cancer patients between Sweden and the Netherlands. SUMMARY OF BACKGROUND DATA: Identification of inter-country differences in treatment allocation and survival may be used for targeted esophageal cancer care improvement. METHODS: Nationwide datasets were acquired from a Swedish cohort study and the Netherlands Cancer Registry. Patients with potentially curable (cT1-T4a/Tx, cN0/+, cM0/x) esophageal adenocarcinoma or squamous cell carcinoma (SCC) diagnosed in 2011-2015 were included. Multivariable logistic regression provided odds ratios (OR) for treatment allocation, and multivariable Cox model provided hazard ratios (HR) for overall survival, all with 95% confidence intervals (CI), adjusted for age, sex, year, tumor sub-location and stage. RESULTS: Among 1980 Swedish and 7829 Dutch esophageal cancer patients, Swedish patients were older (71 vs 69 years, P

Objective To examine 5-year survival in esophageal cancer after minimally invasive esophagectomy (MIE) compared to open esophagectomy (OE). Summary background data MIE is becoming an increasingly common approach in the surgical treatment of esophageal cancer. A recent meta-analysis suggested 18% lower 5-year all-cause mortality after MIE compared to OE, but the quality of the included studies was limited. Methods Population-based cohort study including almost all patients who underwent elective esophagectomy for esophageal cancer in Sweden or Finland in 2010-2016, with follow-up until 2020. Cox regression was used to provide hazard ratios (HRs) with 95% confidence intervals (CIs) of all-cause 5-year mortality (main outcome) after MIE (hybrid or total) versus OE. Adjustments were made for age, sex, comorbidity, pathological tumor stage, histological tumor type, neoadjuvant chemo(radio)therapy, country, and annual hospital volume of esophagectomy. Results Among all 1,264 patients, 470 (37.2%) underwent MIE and 794 (62.8%) underwent OE. MIE was associated with an 18% decreased risk of all-cause 5-year mortality, compared to OE (adjusted HR 0.82, 95% CI 0.67-1.00 [P = 0.048]). The HR of all-cause 5-year mortality was seemingly lower after total MIE compared to OE (adjusted HR 0.77, 95% CI 0.60-0.98) than after hybrid MIE compared to OE (adjusted HR 0.87, 95% CI 0.68-1.11). Conclusions This bi-national study indicates that MIE is associated with a higher 5-year survival than OE in patients with esophageal cancer, and that the survival benefit is greater after total MIE than hybrid MIE.

Objective To examine the hypothesis that survival in esophageal cancer increases with more removed lymph nodes during esophagectomy up to a plateau, after which it levels out or even decreases with further lymphadenectomy. Summary background data There is uncertainty regarding the ideal extent of lymphadenectomy during esophagectomy to optimize long-term survival in esophageal cancer. Methods This population-based cohort study included almost every patient who underwent esophagectomy for esophageal cancer in Sweden or Finland in 2000-2016 with follow-up through 2019. Degree of lymphadenectomy, divided into deciles, was analyzed in relation to all-cause 5-year mortality. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (95% CI) adjusted for all established prognostic factors. Results Among 2,306 patients, the 2nd (4-8 nodes), 7th (21-24 nodes) and 8th decile (25-30 nodes) of lymphadenectomy showed the lowest all-cause 5-year mortality compared to the 1st decile (HR = 0.77, 95% CI 0.61-0.97, HR = 0.76, 95% CI 0.59-0.99, and HR = 0.73, 95% CI 0.57-0.93, respectively). In stratified analyses, the survival benefit was greatest in decile 7 for patients with pathological T-stage T3/T4 (HR = 0.56, 95% CI 0.40-0.78), although it was statistically improved in all deciles except decile 10. For patients without neoadjuvant chemotherapy, survival was greatest in decile 7 (HR = 0.60, 95% CI 0.41-0.86), although survival was also statistically significantly improved in deciles 2, 6, and 8. Conclusion Survival in esophageal cancer was not improved by extensive lymphadenectomy, but resection of a moderate number (20-30) of nodes was prognostically beneficial for patients with advanced T-stages (T3/T4) and those not receiving neoadjuvant therapy.

Evaluate the existing literature comparing long-term survival after minimally invasive esophagectomy (MIE) and open esophagectomy (OE), and conduct a meta-analysis based on relevant studies.It is unknown whether the choice between MIE and OE influences the long-term survival in esophageal cancer.A systematic electronic search for articles was performed in Medline, Embase, Web of Science, and Cochrane Library for studies comparing long-term survival after MIE and OE. Additionally, an extensive hand-search was conducted. The I test and χ test were used to test for statistical heterogeneity. Publication bias and small-study effects were assessed using Egger test. A random-effects meta-analysis was performed for all-cause 5-year (main outcome) and 3-year mortality, and disease-specific 5-year and 3-year mortality. Meta-regression was performed for the 5-year mortality outcomes with adjustment for the covariates age, physical status, tumor stage, and neoadjuvant or adjuvant therapy. The results were presented as hazard ratios (HRs) with 95% confidence intervals (CIs).The review identified 55 relevant studies. Among all 14,592 patients, 7358 (50.4%) underwent MIE and 7234 (49.6%) underwent OE. The statistical heterogeneity was limited [I = 12%, 95% confidence interval (CI) 0%-41%, and χ = 0.26] and the funnel plot was symmetrical both according to visual and statistical testing (Egger test = 0.32). Pooled analysis revealed 18% lower 5-year all-cause mortality after MIE compared with OE (HR 0.82, 95% CI 0.76-0.88). The meta-regression indicated no confounding.The long-term survival after MIE compares well with OE and may even be better. Thus, MIE can be recommended as a standard surgical approach for esophageal cancer.

Background Studies examining hospital volume for surgery for various gastrointestinal (GI) cancer types have shown conflicting results regarding the influence on long-term prognosis. The aim of this study was to examine annual hospital volume in relation to long-term survival after elective surgery for all GI cancers (esophagus, stomach, liver, pancreas, bile ducts, small bowel, colon, and rectum). Methods Population-based cohort study including all 45,908 patients who underwent elective surgery for GI cancers in Sweden in 2005–2013. Follow-up was until 2016 for disease-specific 5-year mortality (main outcome) and 2018 for all-cause 5-year mortality (secondary outcome). Hospitals were divided into quartiles for each GI cancer according to a 4-year average annual volume of the year of surgery and three years earlier. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for relevant confounders. Results Higher hospital volume was associated with a survival benefit in the large group of patients (n = 26,688) who underwent colon cancer resection, with HR 0.89 (95% CI 0.84–0.96) for disease-specific 5-year mortality comparing the highest with the lowest quartile. Higher hospital volume improved 5-year mortality in sub-groups of patients who underwent surgery for cancer of the esophagus, pancreas, and rectum. No such improvements were found for cancer of the stomach, liver, bile ducts, or small bowel. Conclusion Long-term survival was improved at higher volume hospitals for some GI cancers (colon, esophagus, pancreas, rectum), but not for others (stomach, liver, bile ducts, small bowel).

ObjectivesThe public health disorder gastro-oesophageal reflux disease (GORD) is linked with several comorbidities, including oesophageal adenocarcinoma (OAC), but whether life expectancy is reduced by GORD is uncertain. This study assessed all-cause and cancer-specific mortality in GORD after controlling for confounding by heredity and other factors.DesignPopulation-based cohort study from 1998 to 2015.SettingSwedish nationwide study.ParticipantsTwins (n=40 961) born in 1958 or earlier in Sweden.ExposureGORD symptoms reported in structured computer-assisted telephone interviews.OutcomesThe primary outcome was all-cause mortality and the secondary outcome was cancer-specific mortality among twins with GORD and twins without GORD. HRs and 95% CIs were analysed using parametric survival models, both in individual twin analyses and co-twin pair analyses, with adjustment for body mass index, smoking, education and comorbidity.ResultsAmong 40 961 individual twins, 5812 (14.2%) had GORD at baseline and 8062 (19.7%) died during follow-up of up to 16 years. The risks of all-cause mortality (HR=1.00, 95% CI: 0.94–1.07) and cancer-specific mortality (HR=0.99, 95% CI: 0.89–1.10) were not increased in individual twins with GORD compared with individual twins without GORD. Similarly, there were no differences in mortality outcomes in within-pair analyses. The OAC-specific mortality rate was 0.45 (95% CI: 0.32–0.66) per 1000 person-years in individual twins with GORD and 0.22 (95% CI: 0.18–0.27) per 1000 person-years without GORD, rendering an adjusted HR of 2.01 (95% CI: 1.35–2.98).ConclusionsGORD did not increase all-cause or cancer-specific mortality when taking heredity and other confounders into account. The increased relative risk of mortality in OAC was low in absolute numbers.

Background Surgery proficiency gain curves must be shortened to reduce patient harm during esophagectomy learning. Objective This study aimed to test whether surgeon volume and surgeon age influenced the length of period of surgical proficiency gain. Methods This population-based cohort study included 1384 patients with esophageal cancer who underwent esophagectomy by any of the 36 highest-volume surgeons in Sweden between 1987 and 2010, with follow-up until 2016. Annual surgeon volume was dichotomized by the median values into ‘higher-volume surgeons’ (≥ 4 cases per year) and ‘lower-volume surgeons’ (

ObjectiveGastro-oesophageal reflux is a public health concern which could have associated oesophageal complications, including adenocarcinoma, and possibly also head-and-neck and lung cancers. The aim of this study was to test the hypothesis that reflux increases all-cause and cancer-specific mortalities in an unselected cohort.DesignThe Nord-Trøndelag health study (HUNT), a Norwegian population-based cohort study, was used to identify individuals with and without reflux in 1995–1997 and 2006–2008, with follow-up until 2014. All-cause mortality and cancer-specific mortality were assessed from the Norwegian Cause of Death Registry and Cancer Registry. Multivariable Cox regression was used to calculate HRs with 95% CIs for mortality with adjustments for potential confounders.ResultsWe included 4758 participants with severe reflux symptoms and 51 381 participants without reflux symptoms, contributing 60 323 and 747 239 person-years at risk, respectively. Severe reflux was not associated with all-cause mortality, overall cancer-specific mortality or mortality in cancer of the head-and-neck or lung. However, for men with severe reflux a sixfold increase in oesophageal adenocarcinoma-specific mortality was found (HR 6.09, 95% CI 2.33 to 15.93) and the mortality rate was 0.27 per 1000 person-years. For women, the corresponding mortality was not significantly increased (HR 3.68, 95% CI 0.88 to 15.27) and the mortality rate was 0.05 per 1000 person-years.ConclusionsIndividuals with severe reflux symptoms do not seem to have increased all-cause mortality or overall cancer-specific mortality. Although the absolute risk is small, individuals with severe reflux symptoms have a clearly increased oesophageal adenocarcinoma-specific mortality.