Active surveillance may be a viable option for select esophageal cancer patients achieving clinical complete response after neoadjuvant chemoradiation, but esophagectomy secures superior long-term survival.

• At 5 years, standard esophagectomy outperformed active surveillance with 1.74 vs 1.34 quality-adjusted life-years (QALYs) and 3.11 vs 2.41 life-years.
• Active surveillance showed short-term benefits, with a 2-year QALY gain of 15 days, consistent with prior SANO trial results.

Surgeons should consider recurrence risk and patient health when deciding between treatment strategies.

• Active surveillance favored when recurrence risk is <43% or negative quality-of-life impact of surgery is significant.