SSAT - PREDICTORS OF UPSTAGING IN EARLY ESOPHAGEAL CANCER: IS CLINICAL STAGING IMPROVING OVER TIME?

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PREDICTORS OF UPSTAGING IN EARLY ESOPHAGEAL CANCER: IS CLINICAL STAGING IMPROVING OVER TIME?
Susheian Kelly^*¹, Rajika Jindani¹, Lamisha Shah¹, Tamar Noble², Marc Vimolratana², Neel Chudgar², Brendon Stiles²
¹Surgery, Albert Einstein College of Medicine, Perth Amboy, NJ; ²Montefiore Medical Center, Bronx, NY

Introduction
Underestimating esophageal cancer staging may have devastating implications for survival and delay systemic treatment for patients with more advanced disease. With advances in diagnostic technology and treatment of esophageal cancer, it is unknown whether the accuracy of clinical staging has also improved. This study longitudinally assesses the accuracy of clinical staging in early esophageal cancer in patients who had upfront surgery and identifies risk factors for upstaging.

Methods
The National Cancer Database (2004-2019) was queried for patients with clinical stage 1-2A esophageal cancer of all histological subtypes who had formal esophagectomy without neoadjuvant treatment. Patients were categorized into two groups: same or downstaged vs upstaged based on final pathology. Chi-squared test was used to assess trends in upstaging from 2004-2019 and identify risk factors for upstaging.

Results
A total of 6,169 subjects were included, of which, 1,366 (22%) were upstaged. Upstaging was analyzed based on period of diagnosis: 21% of subjects were upstaged between 2004-2007, 22% 2008-2011, 23% 2012-2015 and 23 % 2016-2019 (Figure 1A). There was no statistically significant difference in upstaging from 2004-2019, neither by year of diagnosis nor period diagnosis, p=0.072 and p=0.071 (Fig 1B). Factors associated with upstaging were identified (Figure 1C). These include facility type, (Community based 26%, Academic/research center 20%, Integrated cancer network 22%, p<0.001), presence of lymphovascular invasion (absent 14%, present 52%, p<0.001), tumor grade (I 6.9%, II 20%, III 34%, IV 37%, p<0.001) and number of lymph nodes examined (0 nodes 7%, 1-15 20%, 16-30 26%, >30 31%, p<0.001). A lower proportion of clinical stage 1 subjects were upstaged (n=950, 21%), compared to clinical stage 2 patients (n=416, 26%), =<0.001.

Conclusion
Despite advancements in diagnostic modalities, the accuracy of clinical staging for esophageal cancer has not significantly changed over 15 years. Over one-fifth of clinical stage I-2A patients are understaged, and at risk of delayed or inadequate systemic therapies. Multidisciplinary evaluation of factors associated with upstaging is critical to ensure initiation of appropriate treatment algorithms.

Figure 1A) Upstaging by period of diagnosis and year of diagnosis in subjects with stage 1-2A esophageal cancer who had upfront esophagectomy. Figure 1B) Bar graph of percent of subjects upstaged by period of diagnosis and year of diagnosis from 2004-2019. Figure 1C) Statistically significant factors associated with upstaging.

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