BACKGROUND: In an effort to improve the cure rates associated with surgical therapy, neoadjuvant chemoradiotherapy is being used with increasing frequency before resection (trimodality therapy). A variety of clinical trials have reviewed this approach, but only one study to the authors' knowledge has shown a survival benefit for trimodality therapy. The extent to which trimodality therapy has gained acceptance in general practice is not clear. The objective of the current study was to determine the extent to which both surgery and trimodality therapy are used for the management of esophageal carcinoma within a large, national health care system and to determine the outcome of patients treated with these treatment approaches. METHODS: The current study was a retrospective cohort study. The study population was comprised of all veterans who underwent either surgery alone or trimodality therapy for operable esophageal carcinoma between the fiscal years of 1993 and 1997. Data were obtained from the Veterans Administration Patient Treatment File, Outpatient Clinic File, and the Beneficiary Identification Record Locator System. The main outcome measures were perioperative mortality and patient survival. RESULTS: During the study period, 695 patients underwent either surgery alone or trimodality therapy for esophageal carcinoma. Five hundred thirty-four (77%) patients were treated with surgery only. One hundred sixty-one (23%) patients underwent surgery after induction chemoradiotherapy (trimodality therapy). Patients selected for trimodality therapy were younger (mean age, 60.8 years vs. 65.6 years), had fewer comorbidities, and were more likely to have a midesophageal tumor. The median survival for all patients was 15.2 months. The type of treatment had no apparent effect on survival. Favorable prognostic factors included younger age, a distal esophageal tumor, and the absence of metastases. The overall perioperative mortality was 13.7 %. The use of trimodality therapy did not increase perioperative mortality. CONCLUSIONS: Trimodality therapy is commonly used within the VA system. The nonrandomized nature of this study does not allow comparison of trimodality therapy to surgery alone, but the overall survival was limited for all patients. The predictors of survival are related to the biology of the disease, and they include patient age, tumor location, and stage at diagnosis.