Utilization Trends and Volume-Outcomes Relationship of Endoscopic Resection for Early Stage Esophageal Cancer

OBJECTIVES We describe utilization trends and center volume-outcomes relationship of endoscopic resection of early stage esophageal cancer using a large hospital-based registry. SUMMARY BACKGROUND DATA Endoscopic resection is increasingly accepted as the preferred treatment for early stage esophageal cancer, however its utilization and the center volume-outcomes relationship in the United States is unknown. METHODS The National Cancer Database was used to identify patients with cT1N0M0 esophageal cancer treated with endoscopic resection or esophagectomy between 2004 and 2015. Relative frequencies were plotted over time. Restricted cubic splines and maximally selected rank statistics were used to identify an inflection point of center volume and survival. RESULTS 1136 patients underwent ER and 2829 patients underwent esophagectomy during the study period. Overall utilization of ER, as well as relative use compared to esophagectomy, increased throughout the study period. Median annualized center ER volume was 1.9 cases per year (IQR 0.5-5.8). Multivariable Cox regression showed increasing annualized center volume by one case per year was associated with improved survival. Postoperative 30- or 90-day mortality, 30-day readmission, and pathologic T upstaging rates were similar irrespective of center volume. CONCLUSIONS Utilization of ER compared to esophagectomy for stage I esophageal cancer has increased over the past decade, though many individual centers perform fewer than 1 case annually. Increasing annualized center volume by one procedure per year was associated with improved survival. Increased volume beyond this was not associated with survival benefit. Referral to higher volume centers for treatment of superficial esophageal cancer should be considered.