Active Surveillance Matches Surgery Survival in Esophageal Cancer Trial
Active surveillance yields a 5-year overall survival rate comparable to immediate surgery for patients with locally advanced esophageal cancer who achieve a complete clinical response after chemoradiation, according to updated findings presented at the European Society for Medical Oncology 2026 annual meeting in Madrid. Among 309 participants in the non-inferiority SANO trial, roughly half of the patients in both treatment groups remained alive at a median follow-up of 76 months.
Survival Rates and Metastasis Risks in the SANO Trial
The cluster-randomized SANO trial assigned 198 patients to active surveillance and 111 patients to standard esophagectomy after neoadjuvant chemoradiotherapy. At a median of 76 months, the 5-year overall survival rate reached 50% in the active surveillance group compared to 54% in the standard surgery group, yielding a hazard ratio of 1.17 that was not statistically significant. Disease-free survival showed similar alignment at 42% for surveillance versus 50% for surgery.
Despite the matching overall survival figures, distant metastases occurred more frequently under active surveillance, affecting 46% of patients compared to 29% in the surgery arm. Cause-specific mortality data tracked this divergence, showing esophageal cancer deaths at 40% for the surveillance group versus 30% for the surgical cohort. Within the active surveillance arm, 16% of participants developed distant metastases, with 11% emerging during the first six months following chemoradiotherapy.
Organ Preservation and Quality of Life Trade-Offs
Active surveillance successfully spared 43% of trial participants from undergoing an esophagectomy, combining the 32% of patients who maintained a complete clinical response with the 11% who rapidly developed metastatic disease. Standard esophagectomy procedures carry a 60% complication rate and heavily impact patient health-related quality of life. Presenter Sanjiv Gangaram Panday of Erasmus University Medical Center in Rotterdam noted that the surveillance strategy delivered a better short-term health-related quality of life alongside proven cost-effectiveness.
Filippo Pietrantonio of Fondazione IRCCS Istituto Nazionale dei Tumori in Milan cautioned that similar overall survival does not establish long-term oncological safety or equivalent disease control. Pietrantonio noted that the surgery arm lacked adjuvant nivolumab treatment for patients with residual disease, which could have improved disease-free survival outcomes.
High-Volume Centers Should Manage Active Surveillance Protocols
Filippo Pietrantonio suggested that active surveillance be restricted to experienced, high-volume medical centers for carefully selected patients. The surveillance protocol required clinical response evaluations every three months during the first year, every four months in the second year, and every six months thereafter. Patients showing residual disease or local regrowth without distant metastases underwent delayed esophagectomy.
Future monitoring strategies may incorporate circulating tumor DNA to refine patient selection and trigger earlier clinical reassessment when ctDNA clearance fails. Clinical teams emphasize that upfront treatment decisions must account for tumor histology, resectability, and overall patient fitness while fully informing patients of the heavy monitoring requirements and recurrence risks.
Frequently Asked Questions About Esophageal Cancer Active Surveillance
What percentage of patients avoided surgery in the SANO trial?
Active surveillance allowed 43% of trial participants to avoid an esophagectomy. This total includes 32% who maintained a complete clinical response and 11% who developed rapid metastatic disease shortly after chemoradiotherapy.
How often were patients monitored during active surveillance?
Patients in the active surveillance group underwent planned clinical response evaluations every 3 months during the first year, every 4 months in the second year, and every 6 months thereafter.
What were the main risks identified in the active surveillance group?
Patients undergoing active surveillance experienced a significantly higher rate of distant metastases at 46% compared to 29% in the surgery group, alongside an increased rate of deaths specifically caused by esophageal cancer.
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