PD02.06. The ``Invisible Cost'' After Minimally Invasive Esophagectomy: Clinical Characteristics, Survival Impact, and Intervention Timing for Patients with Persistent Moderate-to-Severe Symptoms
TL;DR
Symptom persistence does not adversely affect overall survival; its association with improved DFS likely reflects the tumor-control benefit of adjuvant therapy.
Abstract
Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Persistent moderate-to-severe symptoms after minimally invasive esophagectomy (MIE) remain poorly characterized. While patient-reported outcomes (PROs) are increasingly recognized as important endpoints in surgical oncology, the prevalence, risk factors, optimal intervention timing, and prognostic impact of persistent postoperative symptom burden in esophageal squamous cell carcinoma (ESCC) patients have not been systematically evaluated. Understanding these factors is essential for developing evidence-based, timely symptom management strategies to improve postoperative recovery and quality of life. We retrospectively analyzed 345 ESCC patients who underwent MIE at a single tertiary center. Symptoms were assessed using the MDASI, EORTC QLQ-C30, and QLQ-OES18 at baseline through 6 months postoperatively. Persistent moderate-to-severe symptoms at postoperative month 3 were defined by composite criteria (meeting any one): MDASI ≥3 core symptoms scoring ≥4; QLQ-C30 ≥2 functional domains below 66.7; or OES18 ≥2 symptom domains above 33.3. Independent risk factors were identified by multivariable logistic regression. Symptom trajectory analysis identified the critical divergence timepoint. Kaplan–Meier analysis, log-rank tests, multivariable Cox regression, and propensity score matching (1:1, 81 pairs) evaluated associations between symptom persistence and overall survival (OS) and disease-free survival (DFS). At postoperative month 3, 89 patients (25.8%) met criteria for persistent moderate-to-severe symptoms. Independent risk factors were anastomotic leak (OR=7.92, P<0.001), adjuvant therapy (OR=3.05, P<0.001), and smoking history (OR=2.58, P=0.029); male sex was protective (OR=0.34, P=0.013). Predictive model AUC was 0.734. Symptom trajectories diverged at postoperative day 14. Five-year OS (63.5% vs 66.1%, HR=1.16, P=0.478) and DFS (72.9% vs 73.8%, HR=0.87, P=0.554) showed no significant differences. After propensity score matching (81 pairs), OS remained non-significant (HR=0.94, P=0.796), while DFS favored the persistent group (HR=0.55, P=0.029), potentially mediated by higher adjuvant therapy exposure. Approximately one-quarter of post-MIE ESCC patients experience persistent moderate-to-severe symptoms at 3 months, primarily driven by anastomotic leak and adjuvant therapy. Symptom persistence does not adversely affect overall survival; its association with improved DFS likely reflects the tumor-control benefit of adjuvant therapy. Postoperative day 14 represents the critical symptom trajectory divergence point, providing an optimal window for initiating targeted PRO-based intervention.