SAN FRANCISCO — Between 20% and 30% of patients given preoperative induction therapy for cancer of the esophagus show a complete pathologic response. The remaining patients have a median survival time of 12–24 months and are subject to treatment known to considerably lower quality of life, according to paired presentations debating the value of induction therapy at the annual meeting of the American Association for Thoracic Surgery.
Despite anecdotal fears that preoperative chemoradiation increases operative mortality and morbidity, a metaanalysis of six published randomized clinical trials showed an improved 3-year survival rate and reduced locoregional tumor recurrence, compared with surgery alone. The mortality for preoperative chemoradiation therapy was 1.2%, compared with an overall complete pathologic response rate of 21%, according to Mark B. Orringer, M.D., director of the thoracic oncology program at the University of Michigan Medical Center, Ann Arbor.
Dr. Orringer saw additional “secondary benefits” of neoadjuvant chemoradiation therapy, including easier to enforce abstention from alcohol and smoking, and a weight loss of 20–30 pounds before surgery in patients who had a tendency to be markedly obese as a class.
In contrast, citing the same metaanalysis, Gail Darling, M.D., a researcher at Toronto General Hospital, indicated there was no significant improvement in survival at 1 or 2 years and that the 3-year results “are heavily influenced by the single positive trial report” of the six randomized trials studied.
In a disease that is rarely cured, quality of life is an important outcome measure, according to Dr. Darling, and at least 70%–75% of patients treated with induction chemoradiation will not be cured.
“Such patients might have preferred improved quality of life with immediate esophagectomy resulting in the ability to eat until the end of their days, spending the remaining months with family or friends,” she said.
While disagreeing on whether preoperative induction therapy should become the standard of care, both Dr. Orringer and Dr. Darling agreed on the critical requirement for stage-specific decision making.
“Most patients with resectable stage II and III esophageal carcinomas should be offered this treatment,” Dr. Orringer said. Esophagectomy alone is the best course in those with stage I tumors, other contraindicating medical problems, or age greater than 75 years, he noted.
Similarly, citing 5-year survival rates of 76% in stage I patients and 90% in stage 0 patients receiving surgery alone, Dr. Darling concluded, “Such patients do not derive benefit from induction therapy. Stage-specific therapy should be developed as it has for most other cancers.”