BACKGROUND: Neoadjuvant Chemoradiation (nCRT) has been shown to improve survival in patients with Esophageal Adenocarcinoma (EAC). The objective of this study is to assess the patient characteristics associated with tumor downstaging in a large national database. Additionally, we evaluated surgical approach and change in clinical versus pathological staging as predictors of patient survival. METHODS: Using the 2010-2020 National Cancer Database, we identified 6,400 patients with clinical stage 1B to 4A EAC who received nCRT and underwent esophagectomy. Multivariable logistic models were estimated to evaluate odds of downstaging, and complete downstaging. Multivariable marginal Cox proportional-hazard models were estimated to evaluate all-cause mortality hazard. RESULTS: 3285 (51%) patients downstaged (of which 292 [5% of total] completely downstaged), 2430 (38%) had no change in stage, and 685 (11%) progressed. Generally, higher covariate values such as Clinical T, Clinical N, age, and Charlson-Deyo score were associated with higher odds of downstaging and lower odds of complete downstaging. Downstaging was associated with 31% lower risk of death compared to progression (p <
.001) and 17% lower risk of death compared to no change (p <
.001). Regarding surgical approach, when compared with open esophagectomy (OE), robotic-assisted minimally invasive esophagectomy (RAMIE) was associated with 17% lower adjusted risk of death (p = .002) while minimally invasive esophagectomy (MIE) was associated with a 10% decrease in adjusted risk of death (p = .009). CONCLUSION: In patients with EAC who underwent nCRT, pathological downstaging was associated with increased survival compared to no change or progression. Additionally, RAMIE and MIE were associated with lower risk of death compared to OE.