P1.079. Real-World Adoption of Adjuvant Immunotherapy Following Trimodality Therapy for Esophageal Cancer: A National Cancer Database Analysis

Abstract

Abstract Topic Esophageal Cancer: Adjuvant and Neo-Adjuvant Therapies Background Following CheckMate 577 (CM577, 2021), adjuvant nivolumab was approved for patients with esophageal cancer (EC) and residual disease following trimodality therapy. As perioperative paradigms continue to evolve, early adoption patterns may inform implementation of future multimodality strategies. We evaluated adoption trends and factors associated with receipt of guideline-concordant adjuvant immunotherapy. Methods The National Cancer Database (NCDB) was queried for patients with resectable EC undergoing neoadjuvant chemoradiation and esophagectomy (2019-2023) who met criteria consistent with CM577 eligibility: cM0, pathological residual disease, and R0 resection. Patients who did not reach a 90-day postoperative landmark and those who received immunotherapy >120 days after surgery were excluded. Temporal implementation trends were assessed by using 2019 and 2020 as baseline comparators; the primary analysis of predictors of receipt of adjuvant immunotherapy was restricted to patients diagnosed between 2021–2023. High-volume centers were defined as those in the top quintile. A composite postoperative outcome of length of stay (LOS) >14 days or unplanned readmission was used as a surrogate for complications. A multivariable logistic regression model (MVA) was constructed to identify independent predictors of receiving adjuvant immunotherapy. Results Among 4,617 eligible patients, adjuvant immunotherapy use increased from 0.7% in 2019 to 52.5% in 2023 (Figure 1). The primary cohort (2021-2023) included 2,756 patients, of whom 50.7% (1,396) received adjuvant immunotherapy (IO+). The most common reason for non-receipt (IO-) was adjuvant immunotherapy not being part of planned treatment (86.1%, 1171/1360). No differences in administration were observed by age, race/ethnicity, clinical stage, insurance, Charlson-Deyo score, or income. Receipt was associated with shorter postoperative LOS (IO+: 8.0 days [IQR 7.0-10.0], IO-: 9.0 [7.0-13.0], P<0.001), adenocarcinoma histology (IO+: 89.5% [1249/1396], IO-: 85.9%, P=0.008), ypT3-4 (IO+: 46.3% [647/1396], IO-: 41.4% [563/1360], P<0.001), and residual nodal disease (IO+: ypN+ 47.9% [669/1396], IO-: 39.8% [541/1360], P<0.001). On MVA, ypN+ (adjusted OR 1.2, CI 1.0-1.5, P=0.026), squamous histology (adjusted OR 0.7, CI 0.6-0.9, P=0.045), ypM1 (adjusted OR 0.3, CI 0.1-0.8, P=0.019), and minimally-invasive approach (adjusted OR 1.6, CI 1.1-2.2, P=0.013) independently predicted immunotherapy (Figure 2). Conclusion Despite rapid uptake following approval, only half of potentially eligible patients received guideline-concordant adjuvant immunotherapy after trimodality therapy for esophageal cancer. Receipt of adjuvant immunotherapy was most strongly associated with perioperative and pathologic factors, rather than sociodemographic or facility-level characteristics, suggesting physician-level treatment selection rather than access limitations. As multimodality therapy strategies continue to evolve, understanding decision drivers and defining patients most likely to benefit from postoperative therapy will be essential to optimize guideline-concordant care.