Adding surgery to chemoradiotherapy may not benefit locally advanced oesophageal cancer
Adding surgery to chemoradiotherapy for treating locally advanced, resectable oesophageal squamous cell carcinoma did not improve overall survival (OS) of patients, although it might delay locoregional relapse compared with chemoradiotherapy alone, according to a meta-analysis.
“The outcome of patients with oesophageal cancer is generally poor. Although multimodal therapy is standard … [for] people with more advanced disease (T2 toT4 and/or node positive disease) … the benefits of adding surgery to chemoradiotherapy when compared to chemoradiotherapy alone for nonmetastatic oesophageal cancer are unclear,” according to the researchers led by Dr Balamurugan Vellayappan from the Department of Radiation Oncology at National University Hospital, Singapore.
The study included two randomized trials published in six reports involving 431 patients with node-positive and/or at least a T3 thoracic oesophageal carcinoma, of which 93 percent had squamous cell histology. [Cochrane Database Syst Rev 2017;8:CD010511]
Based on evidence rated as “high quality” in the analysis, adding oesophagectomy to chemoradiotherapy did not significantly affect OS compared with chemoradiotherapy alone (hazard ratio [HR], 0.99; p=0.92).
Nonetheless, the addition of oesophagectomy appeared to reduce the risk of locoregional relapse based on moderate-quality evidence (HR, 0.55; p=0.0004), albeit with an increased risk of treatment-related mortality as suggested by low-quality evidence (relative risk [RR], 5.11; p=0.003).
Adding oesophagectomy was also associated with a reduced quality of life in the short term (mean difference, 0.93, 95 percent confidence interval [CI], 0.24–1.62) and a reduced need for salvage procedures, involving either stent placement or dilation, for dysphagia (RR, 0.52, 95 percent CI, 0.36–0.75) compared with chemoradiotherapy alone, based on low- to very low-quality evidence reported in only one of the two trials analysed.
As the trials analysed have specific inclusion criteria, the findings should only be limited to the selected patient groups and may not apply to patients with excluded characteristics such as adenocarcinomas, gastroesophageal junction tumours, distal oesophageal tumours, and nonresponders to chemoradiation induction, according to the authors.
“People who do not respond to chemoradiation, or who have persistent local disease, warrant upfront surgery. In addition, in people where surgery is deferred, they should undergo close surveillance and surgical salvage upon local recurrence,” said the authors.
Large randomized studies which include patients with adenocarcinoma may be warranted in the future to investigate the effects of upfront surgery on survival, they suggested.