Community prevention and standardized clinical treatment jointly improve cancer outcome: Real-world evidence from an esophageal cancer patient cohort study

Extensive efforts have been put into reducing the heavy burden of esophageal squamous cell carcinoma (ESCC) in China. However, the joint impact of prevention and treatment on the long-term overall survival (OS) of ESCC patients remains largely unknown. We consecutively recruited 13,255 ESCC patients from two Chinese centers: the Northern center, located in a high-risk area with abundant screening programs; and the Southern center, situated in a non-high-risk area with improved clinical practices. Inter-center comparison, longitudinal intra-center comparison, and a simulation analysis were conducted to investigate the influence of tumor downstaging and high-quality clinical treatment on OS. During a follow-up period of 12.52 years, the Northern center exhibited higher median survival than the Southern center (6.22 vs. 3.15 years; HR_adjusted = 0.73, 95% CI: 0.69-0.77). Mediation analysis demonstrated that its OS advantage was largely (77.7%) attributed to earlier TNM stage (stage 0-II: 51.3% vs. 24.6%). In temporal analyses, patient survival in the Southern center gradually improved (median survival during 2015-2018 vs. 2009-2014: 3.58 vs. 2.93 years; HR_adjusted = 0.86, 95% CI: 0.79-0.94), coinciding with the progress of treatment-related indices (completeness of TNM staging in discharge diagnosis [from 53.7% to 99.6%], adoption of minimally invasive esophagectomy [from 0.0% to 51.1%] and right thoracic esophagectomy [from 12.4% to 86.4%], etc.). Simulation analysis further demonstrated that integrating both downstaging and high-quality treatment would lead to the best survival. Tumor downstaging and high-quality clinical treatment have a joint impact on ESCC patient survival. Establishing a comprehensive strategy that integrates cancer prevention with optimal clinical treatment is crucial for alleviating the ESCC burden.