Long-term outcomes of patients with esophageal cancer recommended for surgery but treated non-surgically: a Surveillance, Epidemiology, and End Results analysis

Background: Esophageal cancer is a highly aggressive malignancy with a poor prognosis, particularly in regions such as Asia and Africa. Although surgery remains the standard treatment for early- to intermediate-stage esophageal cancer, a substantial proportion of patients who are recommended for surgery in real-world practice ultimately do not undergo cancer-directed resection. This study aimed to compare long-term survival outcomes between patients who were recommended for surgery but did not undergo it and those who did undergo surgery using the Surveillance, Epidemiology, and End Results (SEER) database. Methods: This retrospective cohort study utilized data from the SEER database covering the period 2004 to 2021. A total of 7,106 patients with esophageal cancer were enrolled: 5,138 in the surgical group and 1,968 in the nonsurgical group. Propensity score matching (PSM) was performed to adjust for confounding variables. Kaplan-Meier curves and Cox regression analyses were used to compare overall survival (OS) and cancer-specific survival (CSS) between the two groups. Results: After PSM, patients who underwent surgery had significantly better median OS and CSS compared with the non-surgery group, across multiple factors including age, year of diagnosis, sex, race, income, and tumor location. Notably, surgery was associated with improved survival outcomes in both male and female patients, as well as those with lower esophageal tumors and those diagnosed later in life. The surgical group consistently demonstrated a higher probability of survival, with a significant benefit in both OS and CSS (P