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Neoadjuvant chemoradiation improves outcomes in node-positive esophageal cancer
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Patients with clinically staged node-positive esophageal adenocarcinoma derived a significant OS benefit from neoadjuvant chemoradiation, according to the results of a retrospective analysis.
However, patients with node-negative tumors did not appear to benefit from the addition of neoadjuvant chemoradiation to surgery, according to the researchers.
Moshim Kukar
“Presently, all patients with locally advanced and/or lymph node-positive esophageal adenocarcinoma get neoadjuvant chemoradiation,” Moshim Kukar, MD, assistant professor of surgical oncology at Roswell Park Cancer Institute, told HemOnc Today. “The goal of the study was to identify which patients with esophageal adenocarcinoma derive benefit from neoadjuvant chemoradiation so that we can identify a subset of patients who do not benefit and can avoid adverse events in these patients.”
Kukar and colleagues conducted a retrospective analysis to establish whether the addition of neoadjuvant chemoradiation to surgery yielded similar oncologic outcomes compared with surgery alone in a broad range of patients with esophageal cancer.
The researchers used the American College of Surgeons National Cancer Database to construct their study population (n = 1,309), which the researchers divided into two groups: neoadjuvant chemoradiation plus surgery (n = 539) or surgery alone (n = 770). Of the entire cohort, 47.2% (n = 618) had node-positive disease.
OS at 3 years served as the primary endpoint. Secondary endpoints included margin status, postoperative length of hospitalization, unplanned readmission rate and 30-day mortality.
Median follow-up for the entire cohort was 73.3 months (interquartile range, 64.1-93.5).
A greater proportion of patients who received neoadjuvant chemoradiation plus surgery achieved 3-year OS compared with patients who underwent surgery alone (49% vs. 38%; P < .001).
When the researchers stratified patients based on clinical nodal status, the propensity score-adjusted OS for patients with node-positive tumors who received chemoradiation was significantly improved (HR = 0.52; 95% CI, 0.42-0.66).
However, node-negative patients did not experience a significant OS benefit based on treatment (HR = 0.84; 95% CI, 0.65-1.1).
The researchers acknowledged limitations of their study. Because the database did not provide specific information regarding disease recurrence, their survival analysis was limited to OS. Further, researchers noted that the database does not provide data on other factors that may influence OS, such as the experience level of the operating surgeon or inpatient care team.
“We have created novel calculators utilizing which we can predict which patients will benefit the most from neoadjuvant chemoradiotherapy,” Kukar said in an interview. “These findings will be presented orally at the 2016 Society for Surgical Oncology Annual Cancer Symposium in Boston.”
In an accompanying editorial, Wayne L. Hofstetter, MD, director of the esophageal surgery program at The University of Texas MD Anderson Cancer Center, noted that advancements in precision medicine may help aid the development of appropriate treatment regimens in patients with esophageal cancer.
“Using genetic markers will hopefully eliminate this discussion of unnecessary preoperative therapy,” Hofstetter wrote. “Predicting patients who are at risk for systemic recurrence and targeting vulnerable areas of the tumor genome/expression will provide more opportunity for cure with lower background toxicity. Similarly, patients with markers indicating low risk for recurring within or outside of the surgical field, and those who are potentially curable but markers indicate relative resistance to preoperative therapy, would go straight to resection.” – by Cameron Kelsall
For more information:
Moshim Kukar, MD, can be reached at Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263; email: moshim.kukar@roswellpark.org.
Disclosure: The researchers and Hofstetter report no relevant financial disclosures.
Perspective
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Joshua E. Meyer
This is an interesting and provocative retrospective study of a large database. The data suggest the patient selection that is occurring with routine clinical practice is being done well, as evidenced by the increase in length of stay and surgical mortality in patients who did not undergo chemoradiation.
Although the data suggest that there may be less of a benefit to treating clinically lymph node–negative patients with neoadjuvant therapy, there are several caveats to keep in mind with this historical dataset.
The chemoradiation that was used in these patients was likely more toxic than the standard carboplatin and paclitaxel regimen most commonly used today. Additionally, radiation techniques have become more sophisticated since these patients were treated, decreasing toxicity. Conversely, as imaging has improved — including endoscopic ultrasound — it may be that today’s clinically node-negative population approaches the study’s truly node-negative population, where there was no benefit seen.
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