Korean J Intern Med > Volume 40(2); 2025 > Article
Ryu, Choi, Kim, Park, Jang, and Son: Clinical outcomes of esophageal squamous cell carcinoma in patients aged over 80 years

Abstract

Background/Aims

The clinical outcomes and optimal treatment of esophageal squamous cell carcinoma (ESCC) in elderly patients are unclear. This study aimed to assess the clinical outcomes of ESCC in patients aged ≥ 80 years.

Methods

Medical records of patients diagnosed with ESCC between December 2008 and February 2024 were retrospectively reviewed. In total, 479 patients with ESCC were included and divided into the elderly (n = 52) and younger (n = 427) groups based on age. The clinical outcomes and survival rates, according to treatment, were compared between the two groups.

Results

The median ages of the two groups were 82 years (range, 80–95 yr) and 66 years (41–79 yr). The overall survival was slightly lower in the elderly group; however, no statistical significance (hazard ratio [HR] 1.27, 95% confidence interval [CI] 0.85–1.91; p = 0.238) was observed. No differences were observed in the outcomes or survival between the two groups according to the treatment method (surgery, chemoradiotherapy or radiotherapy alone, and endoscopic resection). The elderly group was more likely to receive no treatment for cancer (30.8% vs. 13.6%, p = 0.002) than the younger group. However, when there was no treatment for cancer in the elderly group, survival was significantly lower than when treatment was administered (HR 0.08, 95% CI 0.03–020; p < 0.001).

Conclusions

In patients with ESCC aged ≥ 80 years, active cancer treatment was beneficial, and the results did not differ from those of younger patients.

Graphical abstract

INTRODUCTION

As life expectancy gradually increases worldwide, the number of elderly patients with cancer is also increasing, creating a burden. It is difficult for elderly patients with cancer to choose a treatment method, and they sometimes worry about whether to treat or not. The standard age for the elderly has gradually increased, and currently, the American Geriatrics Society defines an “older person” as being 75 years or older [1]. Moreover, as the number of elderly individuals with good general condition has increased, the number of elderly cancer patients receiving treatment has also increased.
Esophageal cancer is a representative cancer that occurs in the elderly and has a poor prognosis [2]. Recently, the peak incidence of esophageal cancer has moved to the 70s [3]. The main histological types of esophageal cancer are squamous cell carcinomas (SCCs) and adenocarcinomas (ACs). Although the prevalence of AC is increasing, SCC remains the most common histological type worldwide and is overwhelmingly prevalent in East Asia, including South Korea [46]. Some studies have been conducted on esophageal cancer in the elderly, but SCC has not been separately analyzed in patients aged ≥ 80 years. Therefore, this retrospective observational study aimed to identify clinical outcomes and survival of patients aged ≥ 80 years with esophageal squamous cell carcinoma (ESCC).

METHODS

Patients

The medical records of patients with esophageal cancer treated between December 2008 and February 2024 at Pusan National University Yangsan Hospital were reviewed. In total, 479 patients with histologically confirmed ESCC who underwent follow-up were included in the study. The patients were divided into elderly and younger groups based on age (80 yr). Esophageal cancer was staged according to the American Joint Committee on Cancer staging system, revised 8th edition [7]. The Eastern Cooperative Oncology Group (ECOG) performance status scale and comorbidities of all patients were investigated. The Charlson comorbidity index was measured based on the patients’ comorbidities [8]. All patients in this study had cancer; therefore, the standard for high-risk mortality patients was set at an index of 7. This study was approved by the Ethics Committee of Pusan National University Yangsan Hospital (Institutional Review Board no. 55-2024-065). The requirement for informed consent was waived because the participants’ medical records were anonymized before the analysis.

Surgery

Patients selected for surgery underwent Ivor Lewis esophagectomy with intrathoracic anastomosis and two- or three-field lymph node dissection if there were no anatomical abnormalities. Patients with anatomical abnormalities, such as gastrectomy, underwent colonic or jejunal interposition. Pathological analysis was used to evaluate resection completeness (R0) and lymph node metastasis. Anastomotic leakage was assessed 1 week after surgery using endoscopy and esophagography. Postoperative mortality was defined as mortality within 30 days of surgery or during postoperative hospitalization.

Chemoradiotherapy or radiotherapy alone

Chemoradiotherapy (CRT) was categorized as definitive CRT, performed with curative intent, or neoadjuvant CRT before surgery. Depending on their condition, some patients received definitive radiation therapy (RT), while others underwent palliative RT only for symptom relief. The RT schedules and doses were as follows: (1) Definitive CRT, 2 Gy × 25 fractions for 50 Gy; (2) neoadjuvant CRT, 1.8 Gy × 25 fractions for 45 Gy; and (3) palliative RT, 3 Gy × 10 fractions for 30 Gy. The chemotherapy regimens used for most patients were cisplatin/5-fluorouracil (cisplatin 75 mg/m2 for 1 day and 5-fluorouracil 750 mg/m2/d for 4 days at weeks 1 and 5) or paclitaxel/carboplatin (paclitaxel 50 mg/m2 and carboplatin area under the curve of 2 mg/mL/min on day 1 weekly over 5 weeks).

Endoscopic resection

Some superficial esophageal cancers without evidence of lymph node metastasis on preoperative examination and localized to the mucosa on endoscopic ultrasound were treated with endoscopic resection. Most patients underwent endoscopic submucosal dissection (ESD), and most procedures were conducted under conscious sedation via intravenous midazolam without general anesthesia. If no complications occurred, the patient was discharged 2 days after the procedure. A complete resection was defined as a single-piece resection without fragmentation and tumor-free margins during histological examination. Curative resection was defined as complete resection without submucosal invasion, lymphovascular involvement, or poorly differentiated features of the resected specimen.

Follow-up after treatment

After curative treatment (surgery, definite CRT, or endoscopic resection), endoscopy and chest/abdominal computed tomography (CT) were performed 2–3 months later, every 3 months for the first year, and every 6 months thereafter. Positron emission tomography (PET) was not conducted after surgery or endoscopic resection but was conducted 3–6 months after definitive CRT. Typically, surgery is performed within 2 months after the completion of neoadjuvant CRT; however, some patients are observed without surgery according to the results of the preoperative examination and their condition through a multidisciplinary approach. Clinically, complete response (cCR) after CRT was defined as no evidence of cancer in examinations performed 2–3 months after completing CRT, including endoscopy, endoscopic biopsy, chest/abdominal CT, and PET. For ambiguous examination results due to esophagitis or ulcers following CRT, the examinations were repeated after 2–3 months.

Statistical analysis

Categorical variables are presented as number (%), and continuous variables are presented as median (range). Student’s t-test and chi-square test and/or Fisher’s exact test were used to analyze continuous and categorical variables, respectively, for in-group comparisons. The Kaplan–Meier method was used to estimate survival, and the log-rank test was used to determine significant differences between groups. A Cox regression model was used to estimate the hazard ratio (HR) associated with survival. Statistical significance was set at p < 0.05. The Statistical Package for the Social Sciences version 27.0 (IBM Corp., Armonk, NY, USA) was used for statistical analyses.

RESULTS

Characteristics of the patients

During the study period, 479 patients with histologically confirmed ESCC, were identified and divided into the elderly and younger group. The median age of the patients was 69 years (range, 41–95 yr). The median follow-up period for the patients was 17 months (range, 1–182 mo). The older and younger age groups included 52 and 427 patients, respectively. The median ages of the two groups were 82 years (range, 80–95 yr) and 66 years (41–79 yr), respectively. No differences were observed in sex, tumor location, or cancer stage between the two groups. The elderly group was more likely to receive no treatment for cancer (30.8% vs. 13.6%, p = 0.002). The elderly group was less likely to undergo surgery than the younger group (13.5% vs. 49.4%, p < 0.001) and preferred CRT or radiotherapy alone (36.5% vs. 21.1%, p = 0.014). None of the patients received chemotherapy alone in the elderly group. The elderly group had higher ECOG performance status scale scores and more comorbidities. A Charlson comorbidity index of 7 or higher was significantly more prevalent in the elderly group (21.2% vs. 7.3%, p = 0.002). The baseline characteristics between the two groups are summarized in Table 1.

Surgery

A total of 218 patients underwent surgery, with seven in the elderly group and 211 in the younger group. The median age of the patients in the elderly group who underwent surgery was 82 years, and all patients were male. All patients in the elderly group underwent esophagogastric anastomosis, and most tumors were located in the lower thoracic esophagus (71.4%). In the elderly group, none of the patients received neoadjuvant CRT; however, R0 resection was performed in all patients. No significant difference was found in the postoperative pathological stage between the groups. No significant difference was observed in anastomotic leakage (14.3% vs. 9.5%, p = 0.674) or postoperative mortality (14.3% vs. 10.4%, p = 0.745) between the groups. The incidence of anastomotic strictures did not differ between the two groups (14.3% vs. 16.1%, p = 0.897). In the younger group, 16 patients were classified as stage IV based on surgical results showing that the cancer had invaded adjacent organs or major blood vessels or had 7 or more lymph node metastases. A comparison of the two groups of patients who underwent surgery is summarized in Table 2.

CRT

A total of 109 patients underwent CRT or RT alone, 19 in the elderly group and 90 in the younger group. No significant differences were observed in sex, cancer location, or chemotherapy regimen between the groups. Stage 3 patients were more in the elderly group (73.7% vs. 38.9%, p = 0.009). All patients in the elderly group were administered reduced doses of chemotherapy. The proportions of patients who underwent RT alone (31.6% vs. 15.6%, p = 0.109) and the proportions of patients who did not complete the CRT schedule because of side effects (10.5% vs. 8.9%, p = 0.822) were higher in the elderly group; however, the difference was not statistically significant. Two patients in the younger group died during the CRT. The achievement of cCR after CRT was similar in both groups (47.4% vs. 51.1%, p = 0.767), and no differences were observed between the stages. Among patients who achieved cCR, four in the non-elderly group experienced cancer recurrence during follow-up, resulting in three deaths and one receiving supportive care. The incidence of radiation-induced strictures did not differ between the two groups (15.8% vs. 10.0%, p = 0.468). A comparison between the two groups of patients who underwent CRT, including RT alone, is summarized in Table 3.

Endoscopic resection

Fifty-seven patients underwent endoscopic resection: 10 in the elderly and 47 in the younger groups. No differences were observed in sex or lesion location between the two groups, and most lesions were removed using ESD (80.0% in the elderly group and 93.6% in the younger group). The procedure time (median, 29 vs. 22 min, p = 0.715) and hospitalization duration (median, 4 vs. 4 days, p = 0.408) did not differ between the two groups. Postprocedural complications (one hemorrhage and one perforation) occurred only in the elderly group. No deaths were associated with endoscopic resection. The complete resection (80.0% vs. 80.9%, p = 0.951) and curative resection (60.0% vs. 66.0%, p = 0.720) rates did not differ between the groups. None of the patients in the elderly group received additional treatment even after non-curative resection. Of the 16 patients who underwent non-curative resection in the younger group, three underwent additional esophagectomy, and six underwent RT. During follow-up, no significant difference was observed in stricture occurrence (20.0% vs. 6.4%, p = 0.190) between the two groups. One case of local recurrence occurred in each group after endoscopic resection. The patient in the elderly group was cured with RT, and the patient in the younger group was cured with ESD again. A comparison between the two groups of patients who underwent endoscopic resection is summarized in Table 4.

Survival

The median follow-up period was 11 months (range, 1–104 mo) for the elderly group and 19 months (range, 1–182 mo) for the younger group. Of the surviving patients (25 elderly and 211 younger), the median follow-up duration was 23 months (range, 3–104 mo) for elderly patients and 60 months (range, 5–182 mo) for younger patients.
Overall, patient survival was lower in the elderly group but not statistically different (HR 1.27, 95% confidence interval [CI] 0.85–1.91; p = 0.238) (Fig. 1A). Cancer-specific survival was worse in the elderly group; however, there was no statistical significance (HR 1.42, 95% CI 0.95–2.12; p = 0.084) (Fig. 1B). Survival after surgery (HR 1.37, 95% CI 0.43–4.33; p = 0.597) or CRT including RT alone (HR 0.86, 95% CI 0.41–1.82; p = 0.691) was similar between the two groups (Fig. 1C, D). No deaths were noted among the patients who underwent endoscopic resection in either group. The overall survival rates at 1, 3, and 5 years were 49.8%, 41.6%, and 41.6%, respectively, in the elderly group, and 64.4%, 50.2%, and 49.4%, respectively, in the younger group. The overall survival rates at 1, 3, and 5 years postoperatively were 50.0%, 50.0%, and 50.0%, respectively, in the elderly group and 82.0%, 62.2%, and 60.9%, respectively, in the younger group. The overall survival rates after CRT or RT alone at 1, 3, and 5 years were 62.3%, 44.5%, and 44.5%, respectively, in the elderly group and 59.2%, 45.9%, and 44.2%, respectively, in the younger group.
Figure 2 shows the comparison of survival according to stage between the two age groups. Except for stage 3 (HR 1.69, 95% CI 1.01–2.83; p = 0.045), the two groups did not differ in survival.

Outcomes and survivals of patients over 80 years old

Figure 3A depicts survival according to the treatment method among the patients. All treatments showed superior survival compared to no treatment. Survival after surgery and CRT, including RT alone, was similar in patients over 80 years old (HR 0.82, 95% CI 0.22–3.11; p = 0.774). Figure 3B shows survival rates with and without treatment, which significantly increased with treatment (HR 0.08, 95% CI 0.03–0.20; p < 0.001). The overall survival rates with treatment at 1, 3, and 5 years were 72.5%, 63.9%, and 63.9%, respectively. The overall survival rates without treatment at 1, 3, and 5 years were 5.9%, 0%, and 0%, respectively. There was no difference in comorbidities between the group that received treatment for cancer and the group that did not. However, the survival rate was significantly worse in the group that did not receive treatment for cancer, regardless of the Charlson comorbidity index (Table 5).

DISCUSSION

This study shows that it is better to actively treat patients all with ESCC, even those over 80 years old. Although the number of patients aged over 80 years was small, no differences were observed in outcomes and survival according to each treatment compared with younger patients. However, in actual clinical practice, as in our study, many patients over 80 years of age with esophageal cancer do not receive cancer treatment. Additionally, patients aged over 80 years had more comorbidities. However, no difference was seen in comorbidities when comparing patients who received treatment for cancer with those who did not in our study.
Cancer is the leading cause of death worldwide. The number of new cancer cases and associated deaths continues to rise [9]. As life expectancy increases, the number of patients diagnosed with cancer at an older age also increases. Although cancer treatments have advanced, treating elderly patients with cancer remains a challenge. Esophageal cancer is a representative cancer that occurs frequently in the elderly and its incidence is gradually increasing worldwide [4,10]. The peak incidence of esophageal cancer has moved to the 70s [3,11], and in a large-scale study in the Netherlands, 33% of patients diagnosed were over 75 years old, and 8% were over 85 years old [11]. As the number of elderly individuals with good general condition has increased, the number of elderly patients with esophageal cancer receiving active treatment has also increased [12].
Esophagectomy can be risky for elderly patients owing to its high morbidity and mortality rates [13,14]; however, CRT, another treatment option for esophageal cancer, may be relatively safer than surgery [15]. Among esophageal cancers, ESCC is particularly sensitive to radiation, and thus RT may be more effective [5]. When surgery is performed after neoadjuvant CRT for ESCC, the pathological complete response rate is > 40% [16,17]. Moreover, the guidelines recommend that in ESCC cases, observation instead of surgery is possible when no evidence of disease remains after neoadjuvant CRT [18]. In our study, 109 patients (19 in the elderly group and 90 in the younger group) were followed up with CRT or RT alone, and 55 patients (50.5%) (9 [47.4%] in the elderly group and 46 [51.1%] in the younger group) achieved cCR.
Some comparative studies have been conducted on esophageal cancer in the elderly population, including two meta-analyses on surgery [19,20]. One study defined the elderly as those over 70 years old [20], and another study defined them as those over 80 years old [19]. In both studies, elderly patients had significantly worse postoperative mortality and survival [19,20]. The postoperative mortality of patients aged ≥ 80 years was reported as 0–23% [19]. Although the number of surgical patients in our study was very small (n = 7), only one surgery-related death occurred (14.3 %). Postoperative survival was worse in the elderly group; however, no statistical significance was observed in our study (HR 1.37, 95% CI 0.43–4.33; p = 0.597).
There have been only three studies on CRT, including RT alone, for patients with esophageal cancer aged > 80 years old [2123]. In one study, pulmonary toxicity was higher in elderly patients with esophageal cancer; however, no difference was observed in the survival rate [23]. One study used the Japanese Nationwide Cancer Database and found that CRT, early-stage cancer, and SCC were favorable factors for overall survival in esophageal cancer patients over 80 years old [21]. The most recent study showed that surgery had the best 3-year survival rate in patients with esophageal cancer over 80 years old; however, the survival rate was worse when CRT was performed in T4 patients owing to side effects [22]. In our study, patients over 80 years old had similar survival rates as younger patients after both surgery and CRT, and surgery and CRT did not differ in this regard even when compared among patients over 80 years old.
There are no studies on endoscopic resection in patients with esophageal cancer aged ≥ 80 years; however, there is one study in patients aged ≥ 70 years [24] and another in patients aged ≥ 75 years [25]. In the study comparing patients aged ≥ 70 years, no complications were observed in the elderly group, and the curative resection rate was 84%, which was not different from that in the younger group [24]. In the study comparing patients aged ≥ 75 years, no differences were observed in complications (8%), curative resection rates (77%), or hospital stay after the procedure (8 days) in the elderly group [25]. However, these two studies included only 23 and 13 elderly patients, respectively [24,25]. In our study, 10 patients with esophageal cancer aged ≥ 80 years underwent endoscopic resection, and no differences were observed in the results between the two groups.
This study had some limitations. This was a single-center retrospective study, and elderly patients with ESCC may be in a relatively poor condition; hence, biases in treatment selection were prominent. Second, the number of patients aged ≥ 80 years is inevitably small, and if divided by treatment, the number becomes even smaller. Third, it was difficult to determine whether the deaths of elderly patients were due to cancer or other causes.
In conclusions, many patients with ESCC over 80 years old did not receive treatment for their cancer; however, survival significantly improved when they received any treatment. Compared with younger patients, no differences were observed in outcome and survival between surgery and CRT, including radiotherapy alone, and endoscopic resection was safe in patients aged ≥ 80 years. Therefore, even if patients with ESCC are ≥ 80 years of age, active cancer treatment is recommended. A long-term observational study with a larger number of patients with ESCC is needed in the future.

KEY MESSAGE

1. Patients aged ≥ 80 years with ESCC more often do not receive active cancer treatment.
2. Even among patients aged ≥ 80 years with ESCC, receiving any treatment significantly improved their survival rate, and the clinical results of each treatment did not differ from those of younger patients.

Notes

CRedit authorship contributions
Dae Gon Ryu: conceptualization, methodology, resources, investigation, data curation, formal analysis, validation, writing - original draft, visualization; Cheol Woong Choi: methodology, validation, writing - review & editing, supervision; Su Jin Kim: resources, validation; Su Bum Park: validation; Jin Ook Jang: resources, validation; Bong Soo Son: methodology, validation
Conflicts of interest
The authors disclose no conflicts.
Funding
This work was supported by the National Research Foundation of Korea (NRF) grant funded by Korea government (Ministry of Science and ICT; no. RS-2023-00242011).

Figure 1
Overall survival curves between the two groups. (A) Overall survival between the two groups for all patients. (B) Cancer-specific survival between the two groups for all patients. (C) Survival between the two groups after surgery. (D) Survival between the two groups after chemoradiotherapy.
kjim-2024-201f1.jpg
Figure 2
Comparison of overall survival curves between the two groups according to stages. (A) Stage 1. (B) Stage 2. (C) Stage 3. (D) Stage 4.
kjim-2024-201f2.jpg
Figure 3
Overall survival curves for the elderly group. (A) Survival according to each treatment. (B) Survival compared to with and without treatment. CRT, concurrent chemoradiotherapy; RT, radiation therapy.
kjim-2024-201f3.jpg
kjim-2024-201f4.jpg
Table 1
Baseline characteristics of patients
Variable Age ≥ 80 yr (n = 52) Age < 80 yr (n = 427) p value
Age (yr) 82 (80–95) 66 (41–79) < 0.001
Male 43 (82.7) 386 (90.4) 0.091
Location
 Cervical 6 (11.5) 23 (5.4) 0.087
 Upper thoracic 7 (13.5) 64 (15.0) 0.770
 Mid thoracic 19 (36.5) 193 (45.2) 0.237
 Lower thoracic 20 (38.5) 147 (34.4) 0.565
cStagea)
 I 12 (23.1) 114 (26.7) 0.576
 II 8 (15.4) 81 (19.0) 0.531
 III 25 (48.1) 136 (31.9) 0.021
 IV 7 (13.5) 96 (22.5) 0.140
Initially distant metastasis 5 (9.6) 71 (16.6) 0.198
Main treatment
 Operation 7 (13.5) 211 (49.4) < 0.001
 Chemoradiotherapy or radiotherapy 19 (36.5) 90 (21.1) 0.014
 Endoscopic resection 10 (19.2) 47 (11.0) 0.089
 Chemotherapy 0 (0) 21 (4.9) 0.233
 None 16 (30.8) 58 (13.6) 0.002
ECOG performance status
 0, 1 9 (17.3) 257 (60.2) < 0.001
 2 11 (21.2) 51 (11.9) 0.066
 3 28 (53.8) 114 (26.7) < 0.001
 4 4 (7.7) 5 (1.2) 0.005
Comorbidities
 Hypertension 34 (65.4) 122 (28.6) < 0.001
 Diabetes 16 (30.8) 63 (14.8) 0.004
 Cardiovascular disease 6 (11.5) 21 (4.9) 0.058
 Cerebrovascular disease 8 (15.4) 21 (4.9) 0.005
 COPD 10 (19.2) 24 (5.6) < 0.001
 CKD 5 (9.6) 11 (2.6) 0.013
 Cirrhosis 6 (11.5) 65 (15.2) 0.482
 History of other malignancy 11 (21.2) 80 (18.7) 0.675
Charlson comorbidity index
 < 7 41 (78.8) 396 (92.7) 0.002
 ≥ 7 11 (21.2) 31 (7.3)

Values are presented as median (range) or number (%).

ECOG, Eastern Cooperative Oncology Group; COPD, chronic obstructive pulmonary disease; CKD, chronic kidney disease.

a) Clinical tumor-node-metastasis (cTNM) according to the American Joint Committee on Cancer (AJCC) TNM version 8.

Table 2
Comparison of the two groups that underwent surgery
Variable Age ≥ 80 yr (n = 7) Age < 80 yr (n = 211) p value
Age (yr) 82 (80–90) 65 (48–79) < 0.001
Male 7 (100) 193 (91.5) 0.808
Location
 Cervical 0 (0) 2 (0.9) 0.280
 Upper thoracic 1 (14.3) 30 (14.2) 0.996
 Mid thoracic 1 (14.3) 102 (48.3) 0.113
 Lower thoracic 5 (71.4) 77 (36.5) 0.083
Type of reconstruction
 Esophago-gastric anastomosis 7 (100) 198 (93.8) 0.989
 Esophago-colonic anastomosis 0 (0) 10 (4.7) 0.869
 Esophago-jejunal anastomosis 0 (0) 3 (1.4) 0.376
Neoadjuvant chemoradiotherapy
 Yes 0 (0) 34 (16.1) 0.467
 Pathologic complete remissiona) - 14/34 (41.2) -
R0 resection 7 (100) 186 (88.2) 0.627
pStageb)
 0 0 (0) 14 (6.6) 0.967
 I 2 (28.6) 59 (28.0) 0.972
 II 3 (42.9) 58 (27.5) 0.381
 III 2 (28.6) 64 (30.3) 0.921
 IV 0 (0) 16 (7.6) 0.874
Intraoperative mortality 0 (0) 0 (0) 0.101
Anastomotic leakage 1 (14.3) 20 (9.5) 0.674
Postoperative mortality 1 (14.3) 22 (10.4) 0.745
Anastomotic stricture 1 (14.3) 34 (16.1) 0.897

Values are presented as median (range) or number (%).

a) Absence of histologically identifiable residual cancer.

b) Pathological stage after surgery.

Table 3
Comparison of the two groups that underwent chemoradiotherapy including radiotherapy alone
Variable Age ≥ 80 yr (n = 19) Age < 80 yr (n = 90) p value
Age (yr) 82 (80–89) 68 (41–89) < 0.001
Male 16 (84.2) 82 (91.1) 0.371
Location
 Cervical 4 (21.1) 15 (16.7) 0.648
 Upper 2 (10.5) 18 (20.0) 0.342
 Middle 6 (31.6) 31 (34.4) 0.811
 Lower 7 (36.8) 26 (28.9) 0.494
cStagea)
 I 0 (0) 9 (10.0) 0.304
 II 4 (21.1) 21 (23.3) 0.830
 III 14 (73.7) 35 (38.9) 0.009
 IV 1 (5.3) 25 (27.8) 0.067
Concurrent chemoradiotherapy 13 (68.4) 76 (84.4) 0.109
Chemotherapy resimen
 5-FU + Cisplatin 9 (69.2) 57 (75.0) 0.317
 Paclitaxel + Carboplatin 4 (21.1) 9 (11.8) 0.087
 Others 0 (0) 10 (13.2) 0.327
Chemotherapy dose reduction 13 (100) 33 (43.4) 0.015
Radiotherapy alone 6 (31.6) 14 (15.6) 0.109
Schedule completed 17 (89.5) 82 (91.1) 0.822
Death during treatment 0 (0) 2 (2.2) 0.951
Clinically complete response 9 (47.4) 46 (51.1) 0.767
According to cStagea)
 I - 8/9 (88.9) -
 II 3/4 (75.0) 17/21 (81.0) 0.786
 III 5/14 (35.7) 18/35 (51.4) 0.323
 IV 0/1 (0) 3/25 (12.0) 0.660
Post-radiation stenosis 3 (15.8) 9 (10.0) 0.468

Values are presented as median (range) or number (%).

a) Clinical tumor-node-metastasis (cTNM) according to the American Joint Committee on Cancer (AJCC) TNM version 8.

Table 4
Comparison of the two groups that underwent endoscopic resection
Variable Age ≥ 80 yr (n = 10) Age < 80 yr (n = 47) p value
Age (yr) 82 (80–85) 64 (42–79) < 0.001
Male 9 (90.0) 42 (89.4) 0.952
Location
 Cervical 0 (0) 0 (0) 0.457
 Upper thoracic 0 (0) 1 (2.1) 0.815
 Mid thoracic 8 (80.0) 39 (83.0) 0.822
 Lower thoracic 2 (20.0) 7 (14.9) 0.689
Type of resection
 Endoscopic mucosal resection 2 (20.0) 3 (6.4) 0.190
 Endoscopic submucosal dissection 8 (80.0) 44 (93.6) 0.190
Procedural time (min) 29 (5–78) 22 (7–94) 0.715
Hospitalization day 4 (4–14) 4 (4–8) 0.408
Results of resection
 En-block resection 9 (90.0) 45 (95.7) 0.473
 Complete resection 8 (80.0) 38 (80.9) 0.951
 Curative resection 6 (60.0) 31 (66.0) 0.720
Submucosal invasion 1 (10.0) 8 (17.0) 0.585
Complication
 Bleeding 1 (10.0) 0 (0) 0.105
 Perforation 1 (10.0) 0 (0) 0.105
Additional treatment
 Operation 0 (0) 3 (6.4) 0.746
 Radiotherapy 0 (0) 6 (12.8) 0.430
Progression of stricture 2 (20.0) 3 (6.4) 0.190
Local recurrence 1 (10.0) 1 (2.1) 0.264

Values are presented as median (range) or number (%).

Table 5
Comparison of groups with and without treatment in patients over 80 years of age
Variable Treatment for cancer (n = 36) No treatment for cancer (n = 16) p value
Age (yr) 82 (80–90) 82 (80–95) 0.544
Male 32 (88.9) 11 (68.8) 0.088
Location
 Cervical 4 (11.1) 2 (12.5) 0.885
 Upper thoracic 3 (8.3) 4 (25.0) 0.120
 Mid thoracic 15 (41.7) 4 (25.0) 0.255
 Lower thoracic 14 (38.9) 6 (37.5) 0.924
cStagea)
 I 12 (33.3) 0 (0) 0.056
 II 7 (19.4) 1 (6.3) 0.249
 III 16 (44.4) 9 (56.3) 0.433
 IV 1 (2.8) 6 (37.5) 0.008
Initially distant metastasis 1 (2.8) 4 (25.0) 0.035
ECOG performance status
 0, 1 9 (25.0) 0 (0) 0.101
 2 10 (27.8) 1 (6.3) 0.110
 3 15 (41.7) 13 (81.3) 0.013
 4 2 (5.6) 2 (12.5) 0.398
Comorbidities
 Hypertension 22 (61.1) 12 (75.0) 0.335
 Diabetes 13 (36.1) 3 (18.8) 0.219
 Cardiovascular disease 4 (11.1) 2 (12.5) 0.885
 Cerebrovascular disease 6 (16.7) 2 (12.5) 0.702
 COPD 8 (22.2) 2 (12.5) 0.418
 CKD 5 (13.9) 0 (0) 0.246
 Cirrhosis 3 (8.3) 3 (18.8) 0.290
 History of other malignancy 11 (30.6) 0 (0) 0.068
Charlson comorbidity index
 < 7 30 (83.3) 11 (68.8) 0.241
 ≥ 7 6 (16.7) 5 (31.2)
Survival rate, 1, 3, 5 yr 72.5%, 63.9%, 63.9% 5.9%, 0%, 0% < 0.001
 Charlson comorbidity index < 7 74.9%, 53.5%, 53.5% 9.1%, 0%, 0% < 0.001
 Charlson comorbidity index ≥ 7 100%, 100%, - 0%, 0%, 0% 0.001

Values are presented as median (range) or number (%).

ECOG, Eastern Cooperative Oncology Group; COPD, chronic obstructive pulmonary disease; CKD, chronic kidney disease.

a) Clinical tumor-node-metastasis (cTNM) according to the American Joint Committee on Cancer (AJCC) TNM version 8.

REFERENCES

1. American Geriatircs Societgy (AGS). About older Americans [Internet] New York (NY): AGS, c2020. [cited 2024 Jun 4]. Available from: https://www.americangeriatrics.org/geriatrics-profession/about-geriatrics/about-older-americans.

2. Eisner DC. Esophageal cancer: treatment advances and need for screening. JAAPA 2024;37:19–24.

3. Rustgi AK, El-Serag HB. Esophageal carcinoma. N Engl J Med 2014;371:2499–2509.
crossref pmid
4. Liu CQ, Ma YL, Qin Q, et al. Epidemiology of esophageal cancer in 2020 and projections to 2030 and 2040. Thorac Cancer 2023;14:3–11.
crossref pmid pmc pdf
5. Sánchez-Danés A, Blanpain C. Deciphering the cells of origin of squamous cell carcinomas. Nat Rev Cancer 2018;18:549–561.
crossref pmid pmc pdf
6. Zhang Y. Epidemiology of esophageal cancer. World J Gastroenterol 2013;19:5598–5606.
crossref pmid pmc
7. Rice TW, Patil DT, Blackstone EH. 8th edition AJCC/UICC staging of cancers of the esophagus and esophagogastric junction: application to clinical practice. Ann Cardiothorac Surg 2017;6:119–130.
crossref pmid pmc
8. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383.
crossref pmid
9. Ferlay J, Colombet M, Soerjomataram I, et al. Cancer statistics for the year 2020: an overview. Int J Cancer 2021;149:778–789.
crossref pmid pdf
10. Asombang AW, Chishinga N, Nkhoma A, et al. Systematic review and meta-analysis of esophageal cancer in Africa: epidemiology, risk factors, management and outcomes. World J Gastroenterol 2019;25:4512–4533.
pmid pmc
11. van Blankenstein M, Looman CW, Siersema PD, Kuipers EJ, Coebergh JW. Trends in the incidence of adenocarcinoma of the oesophagus and cardia in the Netherlands 1989–2003. Br J Cancer 2007;96:1767–1771.
crossref pmid pmc pdf
12. Faiz Z, Lemmens VE, Siersema PD, et al. Increased resection rates and survival among patients aged 75 years and older with esophageal cancer: a Dutch nationwide population-based study. World J Surg 2012;36:2872–2878.
crossref pmid pdf
13. Poon RT, Law SY, Chu KM, Branicki FJ, Wong J. Esophagectomy for carcinoma of the esophagus in the elderly: results of current surgical management. Ann Surg 1998;227:357–364.
pmid pmc
14. Tapias LF, Muniappan A, Wright CD, et al. Short and long-term outcomes after esophagectomy for cancer in elderly patients. Ann Thorac Surg 2013;95:1741–1748.
crossref pmid pmc
15. Anderson SE, Minsky BD, Bains M, Hummer A, Kelsen D, Ilson DH. Combined modality chemoradiation in elderly oesophageal cancer patients. Br J Cancer 2007;96:1823–1827.
crossref pmid pmc pdf
16. van Hagen P, Hulshof MC, van Lanschot JJ, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 2012;366:2074–2084.
crossref pmid
17. Yang H, Liu H, Chen Y, et al. Neoadjuvant chemoradiotherapy followed by surgery versus surgery alone for locally advanced squamous cell carcinoma of the esophagus (NEOCRTEC5010): a phase III multicenter, randomized, open-label clinical trial. J Clin Oncol 2018;36:2796–2803.
crossref pmid pmc
18. Ajani JA, D’Amico TA, Bentrem DJ, et al. Esophageal and esophagogastric junction cancers, version 2.2023, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2023;21:393–422.
pmid
19. Han Y, Liu S, Guo W, Zhang Y, Li H. Clinical outcomes of oesophagectomy in elderly versus relatively younger patients: a meta-analysis. Interact Cardiovasc Thorac Surg 2019;29:897–905.
crossref pmid pdf
20. Markar SR, Karthikesalingam A, Thrumurthy S, Ho A, Muallem G, Low DE. Systematic review and pooled analysis assessing the association between elderly age and outcome following surgical resection of esophageal malignancy. Dis Esophagus 2013;26:250–262.
crossref pmid
21. Jingu K, Numasaki H, Toh Y, et al. Chemoradiotherapy and radiotherapy alone in patients with esophageal cancer aged 80 years or older based on the Comprehensive Registry of Esophageal Cancer in Japan. Esophagus 2020;17:223–229.
crossref pmid pdf
22. Shimonosono M, Sasaki K, Tsuruda Y, et al. Clinical outcome after esophagectomy or definitive chemoradiotherapy in elderly patients (≥80 years) with esophageal cancer. Anticancer Res 2022;42:3953–3961.
crossref pmid
23. Xu C, Xi M, Moreno A, et al. Definitive chemoradiation therapy for esophageal cancer in the elderly: clinical outcomes for patients exceeding 80 years old. Int J Radiat Oncol Biol Phys 2017;98:811–819.
crossref pmid
24. Ishii N, Uchida S, Itoh T, et al. Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for superficial esophageal neoplasia. Is it safe for elderly patients? Surg Endosc 2010;24:2110–2119.
crossref pmid pdf
25. Kikuchi O, Mouri H, Matsueda K, Yamamoto H. Endoscopic submucosal dissection for treatment of patients aged 75 years and over with esophageal cancer. ISRN Gastroenterol 2012;2012:671324.
crossref pmid pmc pdf

Editorial Office
101-2501, Lotte Castle President, 109 Mapo-daero, Mapo-gu, Seoul 04146, Korea
Tel: +82-2-2271-6792    Fax: +82-2-790-0993    E-mail: kaim@kams.or.kr                

Copyright © 2025 by Korean Association of Internal Medicine.

Close layer
prev next