Background: Consensus guidelines recommend neoadjuvant therapy in locally advanced esophageal cancer; however, whether this recommendation has been widely adopted is unknown. Therefore, we evaluated the utilization of neoadjuvant therapy in esophageal cancer and its association with outcomes in the United States. Methods: From the National Cancer Data Base all patients with middle and lower third clinical stage I-III esophageal cancers who underwent surgical resection were identified (1998-2007). Multivariable regression models were developed to identify predictors of neoadjuvant therapy use and associated outcomes. Results: We identified 8562 patients who underwent surgical resection for esophageal cancer. In nonmetastatic locally advanced tumors, neoadjuvant therapy use increased (stage II 47.9% to 72.5%; stage III 51.0% to 90.1%; P < 0.001). On multivariable analysis, factors associated with the decreased use of neoadjuvant therapy for stage II and III disease were age ≥75 years, Medicare insurance coverage, Charlson score ≥2, stage II (vs. III) disease, and geographic region. Patients with stage II and III disease who underwent neoadjuvant therapy had a lower risk of positive lymph nodes (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.35-0.55) and positive surgical margins (OR 0.51, 95% CI 0.38-0.69). Thirty-day postoperative mortality rates were not significantly affected by neoadjuvant therapy (OR 0.90, 95% CI 0.66-1.24). A pathologic complete response was observed in 10.8% of patients. The only factor that was predictive of pathologic complete response was squamous cell tumor histology (OR 2.14, 95% CI 1.52-3.02). Conclusions: In surgically treated patients, the use of neoadjuvant trimodal therapy has increased in the past decade; however, opportunities exist to improve adherence to national guidelines.
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