Historically, the outlook for patients with esophageal cancer who undergo surgical resection with curative intent is poor. Because of the high rates of failure, there is a great deal of interest in the possibility of systemic chemotherapy, combined with local surgical treatment.
The results of a recent randomized trial suggest that there may be a survival benefit for patients who undergo this combined treatment. Researchers compared surgical resection as locally practiced, with or without preoperative chemotherapy to investigate whether chemotherapy lengthens survival and affects dysphagia and performance status. Researchers selected a chemotherapy regimen of cisplatin and fluorouracil, which have been demonstrated to be active for both squamous carcinoma and adenocarcinoma, alone or in combination.
Chemotherapy comprised two 4-day cycles of cisplatin (80 mg/m2) by IV infusion over 4 h on day 1 and fluorouracil (1000 mg/m2) daily as a continuous infusion over 96 h, with an interval of 3 weeks between the first day of each cycle. For patients in this group, surgical resection was performed 3-5 weeks after the start of the second cycle of chemotherapy; for the surgery alone group, procedures were done as soon as possible after randomization. Patients were assessed before the start of treatment, on completion of therapy, and at 3, 6, 9, and 12 months from the date of randomization and then every 6 months until death.
Overall and disease-free survival were both better in the combined treatment group when compared to the surgery alone group (p=0.004; hazard ratio of 0.79; 95% CI 0.67-0.93 and p=0.0014; hazard ratio 0.75; 95% CI 0.63-0.89, respectively), with an estimated reduction in risk of 21% for overall survival. No statistically significant differences were found in dysphagia and performance status.
The authors suggest that this regimen should be considered for patients with resectable cancer of the esophagus, and that it may also serve as an appropriate control for further randomized trials designed to identify other beneficial chemotherapy regimens.
- Medical Research Council Oesophageal Cancer Working Party. Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial. Lancet 2002; 359:1727-33.