Chemotherapy With Radiation Works Better in Esophageal Cancer

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Esophagus Cancer Treatment

Using both chemotherapy and radiation for treating cancer of the esophagus is more effective than radiation alone in patients who do not undergo surgery for their cancer and whose cancer has not spread, according to a large review of studies.

Combined treatment, however, is associated with a high level of toxic side effects, and survival rates, while improved, are still very low.

"Based on the available data, when a non-operative approach is selected, (combined chemotherapy and radiation) is superior to (radiation therapy alone) for patients with localized esophageal cancer, but with significant toxicities," write the authors, led by Rebecca Wong, M.D., of Princess Margaret Hospital in Toronto.

The review comprised 19 randomized controlled trials including 11,998 patients who were given either both therapies or radiation alone, for an average of five to six weeks. The survival rate was 5 percent to 12 percent at two years for people receiving the combined therapy versus 3 percent to 6 percent in those receiving radiation therapy alone.

However, the combination treatment group had a 15 percent higher risk of toxic effects from treatment, such as gastrointestinal and blood disorders.

The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

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Cancer of the esophagus represents 1 percent of all U.S. cancers annually but is responsible for 7 percent of annual cancer deaths. It is estimated that in 2005 there were 14,520 new cases of and 13,570 deaths due to esophageal cancer. The cancer tends to spread rapidly, and only 30 percent of patients have cancer that has not spread.

Typical symptoms such as difficulty swallowing; pain in the throat, back, between the shoulder blades or of the breastbone; hoarseness and cough; and weight loss usually occur relatively late in the progression of the disease, resulting in delayed treatment and high mortality rates. Five-year survival rates range from 5 percent to 20 percent.

Heavy alcohol use, smoking and irritation of the esophagus from other disorders can increase the risk of this type of cancer.

Exactly what treatment patients should receive depends on how much the cancer has progressed and the patient's overall health, according to Wong. "Patients who have good performance status, no comorbid conditions and can tolerate surgery better, should be offered surgery," in addition to radiation and chemotherapy, she said. But, she added that combined chemotherapy and radiation alone is the "treatment of choice for patients who are at higher risk for surgery, and potentially for early cancers."

David Paul Kelsen, M.D., chief of gastrointestinal oncology at Memorial Sloan-Kettering Cancer Center, said, "This update confirms a modest but real benefit of (combined chemotherapy and radiation therapy)." Such treatment has been studied since the 1970s, he said, and is used in many types of cancer and is currently a standard of care in several diseases. "We are clearly getting better at providing this treatment," Kelsen said. "If the decision is made to provide radiation therapy, chemotherapy should be given at the same time. Better systemic therapy will continue to improve outcomes, but further research is needed."

Wong agreed that even combination treatment has only a modest effect on survival in patients with esophageal cancer. "Strategies that can enhance local control as well as reducing risk of systemic progression while limiting toxicity are desperately needed for the management of this disease," she said.

For now, the authors conclude that for patients with esophageal cancer who are in otherwise good condition, and who have thoroughly discussed risk-benefit tradeoffs with their physicians, combined chemotherapy and radiation should be considered over radiation alone. However, "for patients with poor performance status the risk of toxicities has to be weighed against the potential benefits."

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