Research Article| Volume 43, ISSUE 4, P788-795, April 2017

Download started.


“What if I do nothing?” The natural history of operable cancer of the alimentary tract

Published:January 18, 2017DOI:



      “Natural history”, or anticipated survival without treatment, is critical for patients weighing risks and benefits of cancer surgery. Current estimates concerning the natural history of cancer includes patients whose poor health precludes treatment; a cohort whose fate is likely distinctly worse than those eligible for surgery (“operable”). The study objective was to evaluate survival among patients recommended for cancer surgery but went untreated, to determine the natural history of “operable” alimentary tract cancer.


      The NCDB was queried for untreated patients with clinical stage I–III esophageal, gastric, colon, and rectal cancer diagnosed between 2003 and 2009. Untreated patients who were recommended for surgery were considered “operable,” while patients coded as surgically ineligible for health reasons were “inoperable.”


      5-year survival of untreated, “operable” alimentary tract cancers varied by clinical stage: esophageal cI = 10.0%, cII = 9.8%, cIII = 4.6%; gastric cI = 9.2%, cII = 5.8%, cIII = 4.3%; colon cI = 18.4%, cII = 5.0%, cIII = 10.4; and rectal cI = 17.1%, cII = 14.0%, cIII = 19.9%. At every timepoint, stage-specific survival of “operable” patients was superior to inoperable patients (p < 0.05). Additionally, median survival among “operable” patients at least doubled “inoperable” patients for each tumor.


      Natural history of patients with “operable” alimentary tract cancer is superior to that of “inoperable” patients. Preoperative counseling should be refined to reflect this distinction.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Surgical Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Siegel R.L.
        • Miller K.D.
        • Jemal A.
        Cancer statistics, 2015.
        CA a Cancer J Clin. 2015; 65: 5-29
        • Lagergren J.
        • Lagergren P.
        Recent developments in esophageal adenocarcinoma.
        CA a Cancer J Clin. 2013; 63: 232-248
        • Sasako M.
        • Sano T.
        • Yamamoto S.
        • et al.
        D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer.
        N Engl J Med. 2008; 359: 453-462
        • Liang J.
        • Fazio V.
        • Lavery I.
        • et al.
        Primacy of surgery for colorectal cancer.
        Br J Surg. 2015; 102: 847-852
        • Tanaka T.
        • Matono S.
        • Nagano T.
        • Shirouzu K.
        • Fujita H.
        • Yamana H.
        Esophagectomy with extended lymphadenectomy for submucosal esophageal cancer: long-term outcomes and prognostic factors.
        Ann Surg Oncol. 2012; 19: 750-756
        • Kelly K.J.
        • Selby L.
        • Chou J.F.
        • et al.
        Laparoscopic versus open gastrectomy for gastric adenocarcinoma in the west: a case-control study.
        Ann Surg Oncol. 2015; 11: 3590-3596
        • In H.
        • Palis B.E.
        • Merkow R.P.
        • et al.
        Doubling of 30-day mortality by 90 Days after esophagectomy: a critical measure of outcomes for quality improvement.
        Ann Surg. 2015; 2: 286-291
        • Bilimoria K.Y.
        • Stewart A.K.
        • Winchester D.P.
        • Ko C.Y.
        The National Cancer Data Base: a powerful initiative to improve cancer care in the United States.
        Ann Surg Oncol. 2008; 15: 683-690
        • Boffa D.J.
        • Hancock J.G.
        • Yao X.
        • et al.
        Now or later: evaluating the importance of chemotherapy timing in resectable stage III (N2) lung cancer in the National Cancer Database.
        Ann Thorac Surg. 2015; 99: 200-208
        • Hancock J.G.
        • Rosen J.E.
        • Antonicelli A.
        • et al.
        Impact of adjuvant treatment for microscopic residual disease after non-small cell lung cancer surgery.
        Ann Thorac Surg. 2015; 99: 406-413
        • Winchester D.P.
        • Stewart A.K.
        • Bura C.
        • Jones R.S.
        The National Cancer Data Base: a clinical surveillance and quality improvement tool.
        J Surg Oncol. 2004; 85: 1-3
        • Greene F.
        • Balch C.
        • Haller D.
        • Morrow M.
        AJCC cancer staging manual.
        6th ed. Springer, 2002
        • Shimkin M.B.
        • Griswold M.H.
        • Cutler S.J.
        Classics in oncology. Survival untreated and treated cancer.
        CA a Cancer J Clin. 1984; 34: 282-294
        • Fujisaki J.
        • Nakajima T.
        • Hirasawa T.
        • et al.
        Natural history of gastric cancer-a case followed up for eight years: early to advanced gastric cancer.
        Clin J Gastroenterol. 2012; 5: 351-354
        • Tsukuma H.
        • Oshima A.
        • Narahara H.
        • Morii T.
        Natural history of early gastric cancer: a non-concurrent, long term, follow up study.
        Gut. 2000; 47: 618-621
        • Bodner E.
        • Pointner R.
        • Glaser K.
        Natural history of early gastric cancer.
        Lancet. 1988; 2: 631
        • Amri R.
        • Bordeianou L.G.
        • Sylla P.
        • Berger D.L.
        The fate of unscreened women in colon cancer: impact on staging and prognosis.
        Am J Surg. 2015; 6: 927-934
        • Guanrei Y.
        • Songliang Q.
        • He H.
        • Guizen F.
        Natural history of early esophageal squamous carcinoma and early adenocarcinoma of the gastric cardia in the People's Republic of China.
        Endoscopy. 1988; 20: 95-98
        • Haruma K.
        • Tokutomi T.
        • Yoshihara M.
        • Sumii K.
        • Kajiyama G.
        Rapid growth of untreated esophageal squamous-cell carcinoma in 10 patients.
        J Clin Gastroenterol. 1991; 13: 129-134
        • Jacob P.
        • Kahrilas P.J.
        • Desai T.
        • et al.
        Natural history and significance of esophageal squamous cell dysplasia.
        Cancer. 1990; 65: 2731-2739
        • Appelman H.D.
        • Umar A.
        • Orlando R.C.
        • et al.
        Barrett's esophagus: natural history.
        Ann N Y Acad Sci. 2011; 1232: 292-308
        • Glimelius B.
        • Ekstrom K.
        • Hoffman K.
        • et al.
        Randomized comparison between chemotherapy plus best supportive care with best supportive care in advanced gastric cancer.
        Ann Oncol Off J Eur Soc Med Oncology/ESMO. 1997; 8: 163-168
        • Odone V.
        • Chang L.
        • Caces J.
        • George S.L.
        • Pratt C.B.
        The natural history of colorectal carcinoma in adolescents.
        Cancer. 1982; 49: 1716-1720
        • Eisenberg B.
        • Decosse J.J.
        • Harford F.
        • Michalek J.
        Carcinoma of the colon and rectum: the natural history reviewed in 1704 patients.
        Cancer. 1982; 49: 1131-1134