Optimal Therapy in Locally Advanced Esophageal Cancer: a National Cancer Database Analysis

Excerpt

There are over 16,000 new patients diagnosed with esophageal cancer each year in the USA.1 With the overall 5-year survival of approximately 18%, it is one of the leading causes of cancer deaths.1 In patients with esophageal cancer, undergoing a complete (R0) resection is the most important predictor of overall survival.2,3 In patients fortunate enough to have their cancer diagnosed at an early stage (stages I–IIA), resection alone without neoadjuvant therapy is currently recommended and has proved to be an acceptable therapy with good long-term survival.4,5 Unfortunately, patients often present at an advanced stage due to the absence of symptoms during the early stages of the disease. There have been several trials over the past decade designed to determine the optimal treatment for locally advanced esophageal cancer. The MAGIC trial published in 2006 was a randomized control trial comparing survival in patients undergoing neoadjuvant chemotherapy and surgery to surgery alone.6 This trial demonstrated that patients undergoing neoadjuvant chemotherapy and surgery had improved survival compared to the surgery alone group. Published in 2008, the CALGB 9781 trial, despite closing early due to poor accrual, did demonstrate a survival advantage in patients undergoing chemoradiation followed by surgery compared to surgery alone in patients with locally advanced esophageal cancer. More recently, the CROSS Trial demonstrated a survival benefit in patients undergoing chemotherapy and radiation prior to surgery compared to surgery alone and is arguably the most notable trial to date regarding neoadjuvant chemoradiation for esophageal cancer.7 Today, most consider the recommended course of treatment in patients with locally advanced esophageal cancer to be neoadjuvant chemotherapy or chemoradiation followed by esophagectomy.5,8 The purpose of this study is to determine what proportion of patients with locally advanced esophageal cancer receive the optimal treatment (neoadjuvant chemotherapy ± radiation followed by an R0 resection) and what factors influence whether patients receive this treatment. …