Decision analytical model of esophagectomy versus active surveillance in clinical complete responders after neoadjuvant chemoradiation

The SANO trial introduced active surveillance (AS) as a noninferior alternative to esophagectomy for patients with esophageal cancer who achieve a clinical complete response (cCR) after neoadjuvant chemoradiation (nCRT). However, concers remain about recurrence risk, long-term survival, and quality-of-life trade-offs with organ-preserving strategies. A decision analytical model using Markov decision analysis and updated SANO trial results found that, over a 5-year horizon, standard esophagectomy resulted in higher quality-adjusted life-years (1.74 versus 1.34) and life-years (3.11 versus 2.41) compared with AS, although AS was favored at a 2-year horizon for QALYs (incremental gain of 15 days), consistent with the SANO trial. Model preference shifted based on recurrence risk, pattern of recurrence (locoregional versus distant), and surgery-related quality-of-life impacts. The authors conclude that while AS may be reasonable for select patients, esophagectomy remains the preferred treatment long term, supporting judicious rather than routine use of organ-preserving strategies.