Title: Long-Term Survival Following Endoscopic and Surgical Treatment of High-Grade Dysplasia in Barrett’s Esophagus
Abstract: Background & Aims: Photodynamic therapy (PDT) for high-grade dysplasia (HGD) in Barrett’s esophagus is a Food and Drug Administration–approved alternative to esophagectomy. Critical information regarding overall survival of patients followed up long-term after these therapies is lacking. Our aim was to compare the long-term survival of patients treated with PDT with patients treated with esophagectomy. Methods: We reviewed records of patients with HGD seen at our institution between 1994 and 2004. PDT was performed 48 hours following the intravenous administration of a photosensitizer using light at 630 nm. Esophagectomy was performed by either transhiatal or transthoracic approaches by experienced surgeons. We excluded all patients with evidence of cancer on biopsy specimens. Vital status and death date information was queried using an institutionally approved Internet research and location service. Statistical analysis was performed using Kaplan–Meier curves and Cox proportional hazards ratios. Results: A total of 199 patients were identified. A total of 129 patients (65%) were treated with PDT and 70 (35%) with esophagectomy. Overall mortality in the PDT group was 9% (11/129) and in the surgery group was 8.5% (6/70) over a median follow-up period of 59 ± 2.7 months for the PDT group and 61 ± 5.8 months for the surgery group. Overall survival was similar between the 2 groups (Wilcoxon test = 0.0924; P = .76). Treatment modality was not a significant predictor of mortality on multivariate analysis. Conclusions: Overall mortality and long-term survival in patients with HGD treated with PDT appears to be comparable to that of patients treated with esophagectomy. Background & Aims: Photodynamic therapy (PDT) for high-grade dysplasia (HGD) in Barrett’s esophagus is a Food and Drug Administration–approved alternative to esophagectomy. Critical information regarding overall survival of patients followed up long-term after these therapies is lacking. Our aim was to compare the long-term survival of patients treated with PDT with patients treated with esophagectomy. Methods: We reviewed records of patients with HGD seen at our institution between 1994 and 2004. PDT was performed 48 hours following the intravenous administration of a photosensitizer using light at 630 nm. Esophagectomy was performed by either transhiatal or transthoracic approaches by experienced surgeons. We excluded all patients with evidence of cancer on biopsy specimens. Vital status and death date information was queried using an institutionally approved Internet research and location service. Statistical analysis was performed using Kaplan–Meier curves and Cox proportional hazards ratios. Results: A total of 199 patients were identified. A total of 129 patients (65%) were treated with PDT and 70 (35%) with esophagectomy. Overall mortality in the PDT group was 9% (11/129) and in the surgery group was 8.5% (6/70) over a median follow-up period of 59 ± 2.7 months for the PDT group and 61 ± 5.8 months for the surgery group. Overall survival was similar between the 2 groups (Wilcoxon test = 0.0924; P = .76). Treatment modality was not a significant predictor of mortality on multivariate analysis. Conclusions: Overall mortality and long-term survival in patients with HGD treated with PDT appears to be comparable to that of patients treated with esophagectomy. See editorial on page 1607; CME quiz on page 1595. See editorial on page 1607; CME quiz on page 1595. Barrett’s esophagus (BE) is a complication of gastroesophageal reflux disease in which the normal squamous lining of the esophagus is replaced by specialized columnar epithelium.1Spechler S.J. Clinical practice Barrett’s esophagus.N Engl J Med. 2002; 346: 836-842Crossref PubMed Scopus (538) Google Scholar Approximately 5%–10% of patients diagnosed with BE are believed to be at risk for developing esophageal adenocarcinoma.2Cameron A.J. Ott B.J. Payne W.S. The incidence of adenocarcinoma in columnar-lined (Barrett’s) esophagus.N Engl J Med. 1985; 313: 857-859Crossref PubMed Scopus (696) Google Scholar Patients with high-grade dysplasia (HGD) on biopsy are at the greatest risk for cancer and are generally referred for treatment.3Buttar N.S. Wang K.K. Sebo T.J. Riehle D.M. Krishnadath K.K. Lutzke L.S. Anderson M.A. Petterson T.M. Burgart L.J. Extent of high-grade dysplasia in Barrett’s esophagus correlates with risk of adenocarcinoma.Gastroenterology. 2001; 120: 1630-1639Abstract Full Text Full Text PDF PubMed Scopus (390) Google Scholar, 4Cameron A.J. Carpenter H.A. 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Cherian R. Dixon A. Long-term follow-up of Barrett’s high-grade dysplasia.Am J Gastroenterol. 2000; 95: 1888-1893Crossref PubMed Google Scholar The conventional treatment for most patients with HGD has been esophagectomy. Despite recent studies indicating ablative therapies might be efficacious in the control of HGD, esophagectomy continues to be recommended, primarily because of concerns of malignancy occurring during long-term follow up.5Edwards M.J. Gable D.R. Lentsch A.B. Richardson J.D. The rationale for esophagectomy as the optimal therapy for Barrett’s esophagus with high-grade dysplasia.Ann Surg. 1996; 223 (; discussion 589–591): 585-589Crossref PubMed Scopus (171) Google Scholar, 7Heitmiller R.F. Redmond M. Hamilton S.R. Barrett’s esophagus with high-grade dysplasia An indication for prophylactic esophagectomy.Ann Surg. 1996; 224: 66-71Crossref PubMed Scopus (307) Google Scholar, 8Heitmiller R.F. Prophylactic esophagectomy in Barrett esophagus with high-grade dysplasia.Langenbecks Arch Surg. 2003; 388: 83-87PubMed Google Scholar, 13Chang L.C. Oelschlager B.K. Quiroga E. Parra J.D. Mulligan M. Wood D.E. Pellegrini C.A. Long-term outcome of esophagectomy for high-grade dysplasia or cancer found during surveillance for Barrett’s esophagus.J Gastrointest Surg. 2006; 10: 341-346Crossref PubMed Scopus (62) Google Scholar, 14DeMeester S.R. Endoscopic mucosal resection and vagal-sparing esophagectomy for high-grade dysplasia and adenocarcinoma of the esophagus.Semin Thorac Cardiovasc Surg. 2005; 17: 320-325Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 15Fernando H.C. Luketich J.D. Buenaventura P.O. Perry Y. Christie N.A. Outcomes of minimally invasive esophagectomy (MIE) for high-grade dysplasia of the esophagus.Eur J Cardiothorac Surg. 2002; 22: 1-6Crossref PubMed Scopus (60) Google Scholar, 16Luketich J.D. Nguyen N.T. Schauer P.R. 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The rationale for esophagectomy as the optimal therapy for Barrett’s esophagus with high-grade dysplasia.Ann Surg. 1996; 223 (; discussion 589–591): 585-589Crossref PubMed Scopus (171) Google Scholar, 7Heitmiller R.F. Redmond M. Hamilton S.R. Barrett’s esophagus with high-grade dysplasia An indication for prophylactic esophagectomy.Ann Surg. 1996; 224: 66-71Crossref PubMed Scopus (307) Google Scholar, 8Heitmiller R.F. Prophylactic esophagectomy in Barrett esophagus with high-grade dysplasia.Langenbecks Arch Surg. 2003; 388: 83-87PubMed Google Scholar, 13Chang L.C. Oelschlager B.K. Quiroga E. Parra J.D. Mulligan M. Wood D.E. Pellegrini C.A. Long-term outcome of esophagectomy for high-grade dysplasia or cancer found during surveillance for Barrett’s esophagus.J Gastrointest Surg. 2006; 10: 341-346Crossref PubMed Scopus (62) Google Scholar, 14DeMeester S.R. Endoscopic mucosal resection and vagal-sparing esophagectomy for high-grade dysplasia and adenocarcinoma of the esophagus.Semin Thorac Cardiovasc Surg. 2005; 17: 320-325Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 15Fernando H.C. Luketich J.D. Buenaventura P.O. Perry Y. Christie N.A. Outcomes of minimally invasive esophagectomy (MIE) for high-grade dysplasia of the esophagus.Eur J Cardiothorac Surg. 2002; 22: 1-6Crossref PubMed Scopus (60) Google Scholar, 16Luketich J.D. Nguyen N.T. Schauer P.R. Laparoscopic transhiatal esophagectomy for Barrett’s esophagus with high grade dysplasia.JSLS. 1998; 2: 75-77PubMed Google Scholar, 17Pera M. Trastek V.F. Carpenter H.A. Allen M.S. Deschamps C. Pairolero P.C. Barrett’s esophagus with high-grade dysplasia: an indication for esophagectomy?.Ann Thorac Surg. 1992; 54: 199-204Abstract Full Text PDF PubMed Scopus (224) Google Scholar, 18Rice T.W. Falk G.W. Achkar E. Petras R.E. Surgical management of high-grade dysplasia in Barrett’s esophagus.Am J Gastroenterol. 1993; 88: 1832-1836PubMed Google Scholar, 19Sujendran V. Sica G. Warren B. Maynard N. Oesophagectomy remains the gold standard for treatment of high-grade dysplasia in Barrett’s oesophagus.Eur J Cardiothorac Surg. 2005; 28: 763-766Crossref PubMed Scopus (47) Google Scholar, 20Headrick J.R. Nichols III, F.C. Miller D.L. Allen M.S. Trastek V.F. Deschamps C. Schleck C.D. Thompson A.M. Pairolero P.C. High-grade esophageal dysplasia: long-term survival and quality of life after esophagectomy.Ann Thorac Surg. 2002; 73 (; discussion 1702–1703): 1697-1702Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar In this study, we aimed to compare the overall survival of a cohort of patients treated with photodynamic therapy (PDT) with a cohort treated with esophagectomy to define long-term outcomes, including risks and causes of death as well as rates of occurrence of esophageal cancer. This was a retrospective cohort study. Patients were referred for evaluation for PDT to the BE Unit by physicians. All patients seen in the BE Unit for endoscopic therapy had received consultation with thoracic surgeons at the Mayo Clinic or in their local hospitals. Patients referred for esophagectomy were usually referred directly by their physicians. Data from a prospectively maintained database were obtained on consecutive patients with BE and HGD who underwent PDT from September 1994 to July 2004 at the BE Unit at the Mayo Clinic (Rochester, MN). Patients with evidence of carcinoma on pretreatment histopathologic analysis (from either mucosal biopsy specimens and/or endoscopic mucosal resection21Conio M. Repici A. Cestari R. Blanchi S. Lapertosa G. Missale G. Della Casa D. Villanacci V. Calandri P.G. Filiberti R. Endoscopic mucosal resection for high-grade dysplasia and intramucosal carcinoma in Barrett’s esophagus: an Italian experience.World J Gastroenterol. 2005; 11: 6650-6655Crossref PubMed Scopus (85) Google Scholar specimens) were excluded. All patients underwent 4-quadrant biopsies every centimeter of the involved esophagus. Patients had their diagnosis of HGD confirmed by 2 experienced gastrointestinal pathologists. Baseline assessments also included endoscopic ultrasonography and endoscopic mucosal resection (EMR) for any mucosal abnormalities. Computed tomographic scans of the chest and upper abdomen were obtained in patients who had any suspicion of malignant disease. PDT was delayed a minimum of 4 weeks if an EMR was performed to allow healing of the EMR site(s). Photosensitizing drugs used included hematoporphyrin derivative (4 mg/kg) in 26 patients (20%) or the commercially available equivalent porfimer sodium (Photofrin; Axcan Pharma, Mont-Saint-Hilaire, Quebec, Canada) at a similar dose of 2 mg/kg in the remainder. Both were administered intravenously 48 hours before photoradiation. Photoradiation was performed using either centering balloons or with a bare cylindrical diffusing fiber. The cylindrical diffusing fibers were either 2.5- or 5.0-cm-long fibers (Fibers Direct, Andover, MA). The cylindrical diffusing fiber was passed through the accessory channel of the endoscope and placed in the center of the esophageal lumen. The light was delivered from a laser (Lambda Plus [Coherent, Palo Alto, CA] or Diomed [Diomed Inc., Andover, MA]) producing 630 nm light with an adjusted power output of 400 mW/cm fiber, delivering a total energy of 200 J/cm fiber energy to the mucosa. Twelve patients received PDT via centering balloons with 5- to 7-cm windows and 7- to 9-cm fibers (for a total of 22 treatments). The deflated balloon was passed into the esophagus over a “spring-tipped” guide wire, the balloon was then endoscopically positioned such that the window of the photoradiating balloon was adjacent to the targeted area of Barrett’s mucosa, and the balloon was inflated to a pressure of 30 mm Hg with air. A pediatric gastroscope was positioned above the centering balloon to verify its position. The light dose applied for balloon photoradiation was 130 J/cm fiber. A second-look endoscopy was performed from 1992 to 1998 in 24–48 hours to assess the adequacy of treatment, and additional photoradiation (50 J/cm) was administered if untreated areas were seen. In 1999, this practice was discontinued because it did not appear that there was any increase in efficacy with the additional treatment. Patients were subsequently evaluated at 3 months after the index PDT treatment. Focal endoscopically visible lesions underwent EMR for diagnostic purposes to determine histology and exclude carcinoma. EMR was performed by initially injecting 5–10 mL of diluted epinephrine (1:100,000) solution into the submucosa underneath the lesion. The initial technique was a variceal ligation method in which a Bard Six-Shooter (Bard Interventional Products, Billerica, MA) and suction were used to retract the lesion of interest and had a band placed over it to create a pseudopolyp, which was then resected. Beginning in April 2000, EMR was performed using a commercially available EMR cap (EMR-001; Olympus America Inc., Center Valley, PA). Mucosal resection was performed by suctioning the lesion into the cap after positioning of a crescent snare. The snare was then closed with application of cautery current removing the tissue.22Prasad G.A. Wang K.K. Lutzke L.S. Lewis J.T. Sanderson S.O. Buttar N.S. Wong Kee Song L.M. Borkenhagen L.S. Burgart L.J. Frozen section analysis of esophageal endoscopic mucosal resection specimens in the real-time management of Barrett’s esophagus.Clin Gastroenterol Hepatol. 2006; 4: 173-178Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar All patients were placed on proton pump inhibitor therapy twice daily following PDT at the standard dose of the proton pump inhibitor. Patients were carefully educated regarding PDT and its complications, especially dysphagia and photosensitivity, by the physicians, nurse practitioner, and clinical coordinators. Follow-up included endoscopic surveillance with biopsies and EMR if indicated, performed every 3 months for 2 years and then every 6 months for 1–2 years if HGD was eliminated. If HGD persisted, patients were followed up at 3-month intervals. If low-grade dysplasia was present, then patients were followed up every 6 months. If only nondysplastic Barrett’s mucosa or normal squamous mucosa was present at 2 years, patients were followed up annually. Data on photosensitivity and stricture formation were prospectively collected. Patients were identified by a retrospective review of all patients with HGD in the Mayo Clinic pathology database who underwent esophagectomy at the Mayo Clinic between 1994 and 2004. All patients underwent esophagectomy performed by experienced thoracic surgeons using either the transthoracic or the transhiatal route. Data extracted by chart review included postoperative course, days to discharge, complications, and follow-up data. Survival (vital status and death date) information for both groups was assessed by using an institutionally approved Internet research and location service (www.accurint.com). Cause of death was obtained from either the medical records and/or the prospective BE Unit database. Data management and statistical analysis were performed using JMP software (version 6.0; SAS Institute Inc, Cary, NC). Baseline continuous data were compared using the 2-sample t test or the Wilcoxon rank sum tests depending on the data normality. Baseline categorical data were compared using the χ2 test (or Fisher exact test when necessary because of small sample size). Overall survival was analyzed with the Kaplan–Meier product limit method. The log-rank statistic was used to compare overall survival between patients treated with PDT and esophagectomy for HGD. Baseline variables (age, sex, length of BE segment, age-adjusted Charlson comorbidity index score, and propensity score) were analyzed as factors affecting overall survival using Cox proportional hazards modeling. (Propensity score is the predicted probability of being in the PDT group based on age, sex, length of BE, and the age-adjusted Charlson comorbidity index. The propensity score was obtained using logistic regression.23D’Agostino Jr., R.B. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group.Stat Med. 1998; 17: 2265-2281Crossref PubMed Scopus (4406) Google Scholar) Estimates of hazard rates and 95% confidence intervals were determined. A total of 199 patients were included in the study, of whom 129 were in the PDT group and 70 were in the surgical group. Patients in the PDT group and the surgical group were followed up for a mean duration of 59 and 61 months, respectively. Patients in the PDT group were older than those in the surgical group, although the sex distribution was similar (Table 1). Patients in the surgical group had a longer BE segment than those in the PDT group. The frequency of associated medical illnesses was comparable between the 2 groups (Table 1) except for cardiac disease, which was more frequent in the PDT group. We compared the baseline surgical risk and functional status of the groups using the American Society of Anesthesiologists (ASA) classification for preoperative risk assessment24Haynes S.R. Lawler P.G. An assessment of the consistency of ASA physical status classification allocation.Anaesthesia. 1995; 50: 195-199Crossref PubMed Scopus (277) Google Scholar and the Eastern Cooperative Oncology Group (ECOG)/Zubrod performance score. We also calculated the age-adjusted Charlson comorbidity index for all patients in both cohorts using an electronic calculator.25Charlson M.E. Pompei P. Ales K.L. MacKenzie C.R. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis. 1987; 40: 373-383Abstract Full Text PDF PubMed Scopus (34492) Google Scholar, 26Hall W.H. Ramachandran R. Narayan S. Jani A.B. Vijayakumar S. An electronic application for rapidly calculating Charlson comorbidity score.BMC Cancer. 2004; 4: 94Crossref PubMed Scopus (399) Google Scholar Although the proportion of patients in the PDT group with a higher ASA score was numerically greater, this difference did not meet statistical significance. Notably, patients in the PDT group had a significantly lower functional status (higher ECOG score) compared with those in the surgical group. The distribution of the age-adjusted Charlson comorbidity index scores in the 2 groups is shown in Figure 1. The median age-adjusted Charlson index also was significantly higher in the PDT group compared with the surgical group (Table 1).Table 1Comparison of Baseline VariablesPDT group (n = 129)Surgical group (n = 70)P valueAge (y), mean (SEM)64.5 (0.9)60.3 (1.3).008Male (%)9487NSBE length (cm), median (interquartile range)5 (3–8.5)7 (5–10.5).003Hypertension (%)3336NSDiabetes mellitus (%)145NSCardiac disease (%)3014.015Pulmonary disease (%)127NSMalignancy (%)53NSASA score 3 and 4 (%)2414NSaObtained using Fisher exact test.ECOG score 2 or more278.5.001aObtained using Fisher exact test.Age-adjusted Charlson comorbidity index, median (IQR)2 (0–4)0 (0–0)<.0001bObtained using Wilcoxon test.NOTE. Cardiac diseases include coronary artery disease, valvular heart disease, and congestive heart failure; pulmonary diseases include chronic obstructive pulmonary disease and restrictive lung diseases; and previous malignancy (in remission) includes lung cancer, breast cancer, prostate cancer, and colon cancer.a Obtained using Fisher exact test.b Obtained using Wilcoxon test. Open table in a new tab NOTE. Cardiac diseases include coronary artery disease, valvular heart disease, and congestive heart failure; pulmonary diseases include chronic obstructive pulmonary disease and restrictive lung diseases; and previous malignancy (in remission) includes lung cancer, breast cancer, prostate cancer, and colon cancer. After the administration of PDT, patients were followed up by serial endoscopic surveillance as described previously. At 1 year, HGD was eliminated in 88% of patients; at 3 years, HGD was eliminated in 86% of patients. We classified failure of PDT as the detection of HGD within 12 months of the initial PDT session; this occurred in 33 patients who were then re-treated with PDT and/or EMR, which led to the eradication of HGD in most of the patients (70%) who failed initial therapy. Recurrence of HGD, defined as HGD detected after 12 months free of HGD, occurred in 10 patients who were subsequently re-treated with EMR and/or multipolar electrocoagulation, resulting in the eradication of HGD in 60% of patients with recurrence. PDT was performed as an outpatient procedure at our institution, with no procedure-related mortality in this cohort of patients. We recently reported the prevalence and predictive factors for stricture formation following PDT at our institution.27Prasad G.A. Wang K.K. Buttar N.S. Wongkeesong L.M. Lutzke L.S. Borkenhagen L.S. Predictors of stricture formation after photodynamic therapy for high-grade dysplasia in Barrett’s esophagus.Gastrointest Endosc. 2007; 65: 60-66Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Stricture formation occurred in 27% of 131 patients (with rates of stricture formation being similar in patients receiving hematoporphyrin derivative and porfimer sodium). Patients required a median of 4 endoscopic dilations for sustained symptomatic relief. All patients were successfully treated endoscopically, except for one patient who developed a perforation following dilation and underwent partial esophagectomy at an outside institution. No patients were readmitted following PDT for related complications within 90 days. Photosensitivity following PDT occurred in 77 patients (60%), of whom 70 patients (91%) had transient mild erythema that responded to conservative measures, 6 patients had localized blistering that responded to topical therapy, and one patient needed oral corticosteroids. During follow-up, 8 patients (6.2%) in the PDT group developed carcinoma. Five patients had intramucosal carcinoma (cancer confined to the mucosa), of whom 4 elected to have esophagectomy and one had EMR and has not had a recurrence to date. Three patients had submucosal cancer detected during surveillance, and all underwent esophagectomy. None of these patients had metastatic lymphadenopathy detected at surgery. Of these 8 cancers, 6 were detected within 12 months and 2 were detected within 18 months of PDT. All 8 patients were alive at the date of last follow-up (June 2005). Two of 26 patients (7.7%) treated with hematoporphyrin derivative developed recurrent cancer compared with 6 of 103 patients (5.8%) treated with porfimer sodium (P = .68). In the surgical group, 9 of 70 patients (12.8%) had evidence of carcinoma within the resected surgical specimen despite preoperative surveillance described previously. Forty-three patients (60%) in the surgical group underwent endoscopic ultrasonography and 11 patients (15%) underwent EMR before surgery. Additionally, endoscopic ultrasonography had been performed in 8 of the 9 patients with cancer on surgical pathology. Four patients had intramucosal cancer, and 5 had submucosal cancer. None of the 9 patients had metastatic lymphadenopathy, and all were alive at last follow-up (June 2005). Median length of hospitalization for esophagectomy was 10 days (interquartile range, 8–13; range, 4–74). Following esophagectomy, one patient died, yielding an operative mortality of 1.4%. The postoperative morbidity rate was 38%. Nine patients (12.6%) were readmitted within 90 days for medical/surgical complications. Nine patients (12.6%) developed anastomotic strictures requiring endoscopic dilation. The overall mortality in the 2 groups was comparable over the mean follow-up period of approximately 5 years (Table 2). Total mortality in the hematoporphyrin derivative–treated group was 19% (5 of 26 patients), compared with 5.8% (6 of 103 patients) in the porfimer sodium group (P = .04). Causes of death in the 2 groups are described in Table 2. Figure 1 compares the overall survival of the 2 groups using the Kaplan–Meier curve. As is evident, the 2 curves overlap, with the log-rank test showing the absence of a significant difference. Figure 2 compares the cancer-free survival of patients in both cohorts. Although cancer-free survival is lower in the PDT group, there is no statistically significant difference between the 2 cohorts (Wilcoxon test = 0.0924, P = .76). Using Cox proportional hazards modeling, overall survival was comparable (Table 3) after adjusting for age, sex, length of BE, the age-adjusted Charlson comorbidity index, treatment modality (PDT or surgery), and propensity scores for patients in the 2 groups.Table 2Comparison of Overall Mortality and Causes of DeathPDT groupSurgical groupFollow-up (mo), mean (±SEM)59 (±2.7)61 (±5.8)Overall mortality (%)11/129 (9)6/70 (8.5)Causes of deathLung cancer, 7Congestive heart failure, 3Pulmonary embolism, 1Pneumonia, 3Postoperative complications, 1Malignant astrocytoma, 1Metastatic transitional cell cancer, 1 Open table in a new tab Table 3Overall and Cancer-free Survival in the PDT and Surgical GroupsVariableHazard ratio (95% confidence interval)P valueOverall patient survival adjusting for covariates1.31 (0.41–4.17).653Overall patient survival adjusting for propensity score1.25 (0.38–4.10).714Cancer-free survival adjusting for all covariates2.45 (0.85–7.12).099Cancer-free survival adjusting for propensity score2.49 (0.84–7.41).102 Open table in a new tab We also calculated the ECOG/Zubrod performance score of patients in both groups at the end of follow-up. Six percent of patients in the surgical group had an ECOG score of ≥2 compared with 27% in the PDT group. This was similar to the pretreatment proportions. This is the first study that reports long-term (5-year) results following the treatment of HGD in BE with endoscopic therapy (PDT and/or EMR) and esophagectomy in terms of overall survival in a large cohort of patients. We found that overall survival in the 2 groups was comparable despite HGD occurring in 30% of PDT-treated patients and progression to cancer in 5.4% of patients in the PDT group. The majority of HGD recurrences were successfully treated endoscopically. Additionally, overall survival between the groups was similar despite 12.7% of the surgical group having cancer ultimately discovered in the resected surgical specimen. Long-term survival remained comparable even though patients in the PDT group had a signif