Active surveillance offers a feasible strategy for improving quality of life and potentially avoiding surgery in patients with locally advanced esophageal cancer who achieve a clinical complete response to neoadjuvant chemoradiation, Medscape reported. Updated findings from the phase 3 SANO trial show that patients undergoing active surveillance maintained a 5-year overall survival rate comparable to those receiving standard surgery.
Can patients with locally advanced esophageal cancer safely avoid surgery after chemoradiation?
Neoadjuvant chemoradiotherapy followed by esophagectomy has long been a standard treatment for locally advanced esophageal cancer. While nearly a third of patients achieve a complete clinical response, 30% to 40% still develop distant metastases, and 60% of patients undergoing esophagectomy experience complications that toll their quality of life, Medscape reported. To test whether some patients can bypass immediate surgery, the SANO trial enrolled 309 patients with locally advanced esophageal cancer who achieved a complete clinical response based on endoscopic biopsies, ultrasound, or PET-CT.
Among the participants, 198 were assigned to active surveillance and 111 underwent esophagectomy. Patients had a median age of 68 to 69 years, 78% were male, and 75% had adenocarcinoma. Active surveillance involved clinical response evaluations every 3 months in the first year, every 4 months in the second year, and every 6 months thereafter. Patients with residual disease or regrowth without distant metastases underwent esophagectomy.
How do overall survival rates compare between active surveillance and standard surgery?
At a median of 76 months of follow-up, the 5-year overall survival rate was similar between the two groups: 50% for the active surveillance group compared with 54% for the standard surgery group, according to data presented by Sanjiv Gangaram Panday of Erasmus University Medical Center in Rotterdam, the Netherlands, and reported by Medscape. Disease-free survival also showed no significant difference, standing at 42% for surveillance and 50% for surgery.
We think these findings support the concept of active surveillance after chemoradiotherapy,
Panday told Medscape. However, distant dissemination rates differed significantly at 46% with surveillance versus 29% with surgery. Researchers noted a higher rate of death specifically from esophageal cancer in the active surveillance group at 40%, compared with 30% in the surgery group. Deaths from other causes showed no significant difference, remaining at about 10% for active surveillance and 15% for surgery.
What percentage of patients successfully avoided an esophagectomy?
Within the active surveillance group, 32% of participants maintained a complete clinical response throughout the monitoring period. Combined with the 11% of patients who rapidly developed metastatic disease after neoadjuvant therapy and were thus spared an unnecessary operation, a total of 43% of patients avoided esophagectomy, Panday reported.
At the same time, 16% of participants on surveillance developed distant metastases—including 11% within the first 6 months following chemoradiotherapy. Also, 51% developed locoregional regrowth, and 1% developed a second primary esophageal tumor. Meanwhile, only 37% of patients in the surgery group had a confirmed pathological complete response, highlighting the difficulty of predicting surgical necessity upfront.
Why do specialists urge caution regarding active surveillance protocols?
Study discussant Filippo Pietrantonio of Fondazione IRCCS Istituto Nazionale dei Tumori in Milan, Italy, told Medscape that the comparable long-term overall survival results must be interpreted cautiously. Similar survival does not mean similar disease control and does not establish long-term oncological safety,
Pietrantonio noted, emphasizing that the trial’s benchmark of clinical complete response does not guarantee a pathological complete response.
Pietrantonio suggested that the approach currently be reserved for select patients treated at experienced, high-volume centers. He advocated that the decision to pursue surgery should be determined upfront when defining the initial treatment strategy, factoring in histology, resectability, and patient fitness. Discussions with patients must include informing them of the intensive monitoring required, alongside the significant risks of locoregional recurrence and distant metastases.
Frequently Asked Questions About Esophageal Cancer Surveillance
What funding sources supported the SANO trial?
The research was funded by the Dutch Cancer Society and the Netherlands Organization for Health Research and Development, as reported by Medscape.
How might circulating tumor DNA influence future treatment decisions?
Filippo Pietrantonio noted that circulating tumor DNA (ctDNA) may aid future treatment choices by helping exclude patients from surveillance strategies when ctDNA fails to clear, while serial monitoring could trigger earlier clinical reassessments.
What were the predominant demographic characteristics of trial participants?
The median age of participants ranged from 68 to 69 years old, 78% of the cohort was male, and 75% of the patients had adenocarcinoma.
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