ESMO 2026 | SANO: active surveillance vs surgery after chemo-RT in esophageal cancer

Neoadjuvant chemoradiotherapy followed by esophagectomy has long been a standard treatment for locally regional esophageal cancer and the SANO trial was initiated because we actually saw that a lot of patients had a pathological complete response after neoadjuvant chemoradiotherapy and esophagectomy. And we know that an esophagectomy has long-term morbidity and effects on health-related quality of life. So the question was, do we really have to operate on all those patients, which is where the SANO trial was initiated. Three years ago, my colleague already presented that there was non-inferiority at two years in overall survival and also we saw better quality of life and there was no difference in post-operative complications and 30-day mortality; we even already presented that it is a cost-effective method and now at five years we still see that there’s no significant difference in overall survival. There is a higher rate of distant metastasis, which is also significant. And to actually look at this paradoxical pattern, what we see is that if we look at cause-specific mortality, we do see that patients die more of esophageal cancer in the active surveillance group, but they die more of non-cancer-related death in the group with standard surgery. However, these are all subgroup analyses and the findings there are really exploratory. So there’s a really paradoxical finding which you cannot completely explain, but we do have an idea that it’s maybe due to this. And we really think that combined with the non-inferiority at two years, the found similar overall survival at five years, the better health-related quality of life, the cost-effectiveness, and the similar operation complications after delayed surgery. We think that this is a valuable option for patients opting for active surveillance.

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