Gustavo Viani, Associate Professor in the Department of Medical Imaging, Hematology, and Oncology at Hospital das Clínicas, shared an article by Berend J van der Wilk, et al. on X:
“Can We Avoid Surgery in Esophageal Cancer?
The SANO Trial Has Answers!
A new phase 3 trial suggests that active surveillance after neoadjuvant chemoradiotherapy (CRT) may be a safe alternative to immediate surgery.
Let’s break it down!
What Was the Question?
For locally advanced esophageal cancer, standard treatment includes CRT followed by surgery. BUT many achieve complete response with CRT alone Should we operate on everyone or monitor and operate only if needed?
Prior Evidence & Rationale 25-50% of patients have pathological complete response after CRT Surgery has high morbidity (60% complications).
Previous small studies suggested similar survival for surveillance vs. surgery.
The SANO trial tested this rigorously!
The SANO Trial: Study Design.
- 12 Dutch centers, stepped-wedge, cluster-randomized.
- 309 with locally advanced esophageal cancer.
- Clinical complete response after CRT (biopsies, PET-CT, endosonography).
- Active Surveillance (monitoring) vs. Immediate Surgery.
Key Findings 2-year OS:
- Active Surveillance: 74%
- Surgery: 71%
- Non-inferior survival!
Half of patients avoided surgery without worse outcomes. Better QoL in active surveillance.
Why Does This Matter?
Spares unnecessary esophagectomies for with durable response. surgical complications while keeping survival intact.
Enables personalized treatment—operate only if progression occurs.
Open Questions & Future Research.
Can liquid biopsy (ctDNA) improve response evaluation?
Could immunotherapy enhance non-surgical approaches?
Are different histologies (SCC vs. adenocarcinoma) equally suitable for surveillance?
Ongoing trials (SANO-3, immunotherapy + surveillance) will shed more light!
Clinical Takeaway:
Active Surveillance is a real option for select patients with esophageal cancer post-CRT.
Not yet standard, but this trial shifts the paradigm toward more personalized approaches!”
Authors: Berend J van der Wilk, et al.
