Active surveillance versus standard surgery after neoadjuvant chemoradiotherapy for oesophageal cancer: long-term results of a cluster-randomised controlled trial (SANO)
In brief
Surveillance spared surgery in 43%, with similar five-year survival
Among 309 patients with no detectable cancer after chemoradiotherapy, five-year survival was 50% with active surveillance and 54% with standard surgery, with no statistically significant difference. Surveillance avoided oesophagectomy in 43% of patients, but distant metastases were more common: 46% versus 29%. The results support surveillance for selected patients, while the higher spread rate remains an important concern.
- Journal
- Annals of oncology : official journal of the European Society for Medical Oncology (Q1)
- Published
- 23 October 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- S S G Gangaram Panday, B J van der Wilk, S M Lagarde, B M Eyck, C Rosman, B J Noordman, et al.
- PMID
- 42918421
- DOI
- 10.1016/j.annonc.2026.10.1290
Why clinicians should know about it
- Picked for Radiation Oncology (paper of the day, 24 October 2026): Long-term surveillance versus surgery after neoadjuvant chemoradiation
- Picked for Oncology and Radiation Oncology (paper of the day, 24 October 2026): Randomized organ-preservation strategy after neoadjuvant chemoradiotherapy
- Picked for Surgical Oncology (paper of the day, 24 October 2026): Cluster RCT shows surveillance non‑inferior to surgery after neoadjuvant CRT
- Picked for Surgery (paper of the day, 24 October 2026): Esophageal cancer surveillance versus oesophagectomy informs operative decisions
Abstract
BACKGROUND: The Surgery As Needed for Oesophageal cancer (SANO)-trial demonstrated that active surveillance is non-inferior to standard surgery in terms of two-year overall survival in patients with a complete clinical response after neoadjuvant chemoradiotherapy (nCRT). Active surveillance resulted in improved quality of life. Here, we report five-year outcomes. METHODS: From 2017 to 2021, a multicentre stepped-wedge cluster-randomised non-inferiority trial was conducted. Patients with locally advanced oesophageal cancer who achieved complete clinical response (defined as no tumour detected on endoscopic biopsies, -ultrasound, or PET-CT) underwent active surveillance or standard surgery. Cox regression was used to compare five-year overall and disease-free survival, and the cumulative incidence of distant metastases was estimated using competing risk analysis. RESULTS: A total of 309 patients were included, 198 underwent active surveillance and 111 underwent standard surgery. Median follow-up was 76 months (IQR 67-86). Five-year overall survival was not statistically significantly different between active surveillance and standard surgery (50%, 95%CI 43-57 vs. 54%, 95%CI 46-64; HR 1.17, 95%CI 0.77-1.77) with similar results across histologic subtypes. Disease-free survival was not statistically significantly different (HR 1.39, 95% CI 0.94-2.06). The cumulative incidence of distant metastases at five years was significantly higher in the active surveillance group compared to the standard surgery group (46%, 95%CI 39-53 vs. 29%, 95%CI 21-37; P<.01). Overall, 85 of 198 patients (43%) avoided oesophagectomy, including those with sustained complete clinical response at last follow-up or distant metastases detected within six months after nCRT. CONCLUSIONS: Overall survival at five years is not statistically significantly different between active surveillance and standard surgery in patients with oesophageal cancer and a complete clinical response after nCRT, despite a higher incidence of distant metastases in the active surveillance group. These findings support active surveillance as a feasible treatment strategy in selected patients.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.