Elsevier

Clinical Oncology

Volume 23, Issue 3, April 2011, Pages 182-188
Clinical Oncology

Original Article
Definitive Chemoradiation for Oesophageal Cancer — a Standard of Care in Patients with Non-metastatic Oesophageal Cancer

https://doi.org/10.1016/j.clon.2010.12.001Get rights and content

Abstract

Aims

A retrospective analysis was carried out of 291 cases of oesophageal cancer treated with definitive chemoradiotherapy (dCRT) at a single UK cancer centre between 1995 and 2009. Our protocol consisted of two cycles of neoadjuvant platinum-based chemotherapy followed by two further cycles given concurrently with 50 Gy of external beam radiotherapy delivered in 25 fractions over 5 weeks.

Materials and methods

Demographic, patient and outcome data were recorded prospectively through an electronic health record and retrospectively analysed, using appropriate statistical tools.

Results

Data on 266 patients were available for analysis. The median age was 66.6 years, 53% were adenocarcinomas. dCRT was used instead of surgery because of age/co-morbidity in 44% and disease extent in 39%. Ninety-three per cent of patients completed treatment according to protocol. Grade 3 and 4 toxicities were seen in 42 and 7%, respectively. Median survival was 20.6 months; 2, 3 and 5 year survival rates were 43.6, 32.9 and 19.5%, respectively. Advanced disease was associated with a worse outcome. Shorter disease length was associated with a better median survival, but some patients with disease >10 cm had long-term disease control. The effect of other patient- and disease-related factors was also analysed.

Conclusion

We present data showing that dCRT is well tolerated and should be considered as an alternative to surgery for all patients with locally advanced oesophageal cancer, not only those with co-morbidity. Furthermore, the benefits of dCRT are not confined to carcinomas with squamous histology.

Introduction

Oesophageal cancer is the ninth most common cancer in the UK and is associated with a 5 year overall survival of only 8% [1]. Where the disease seems to be resectable and patients are sufficiently fit, surgery remains the mainstay of curative therapy. However, many patients present with advanced inoperable disease and this, together with increasing age and co-morbidity, may explain why as few as 10% of all cases of oesophageal cancer undergo surgery in the UK [2]. Definitive chemoradiotherapy (dCRT) is an alternative to surgery that can achieve long-term disease control and cure. Although dCRT has not been compared directly with surgery in randomised trials, outcomes from published studies are similar to those seen in surgical trials in terms of survival and quality of life [3], [4], [5], [6], [7]. Since 1998, patients in South East Wales who are not surgical candidates have been offered dCRT as long as the extent of their disease can be covered in a radical radiation field. Patients may be deemed unsuitable for surgery because of disease extent and/or medical co-morbidity. We have previously presented results on the first 90 patients treated with dCRT [8]; here we present updated results for 266 patients, which, to our knowledge, is the largest published single centre series on outcome after dCRT for oesophageal cancer. We report on changes in treatment since that time in the form of single-phase radiotherapy planning and the use of capecitabine.

Section snippets

Materials and Methods

A retrospective analysis was carried out on 291 patients treated with dCRT at Velindre Cancer Centre between 1 March 1995 and 30 April 2009. Data regarding the disease and treatment for each patient were recorded prospectively on a single electronic health record database (Cancer Network Information System Cymru).

All patients had histologically confirmed adenocarcinoma, squamous cell (SCC) or undifferentiated carcinoma of the oesophagus. Small cell carcinoma was excluded from the analysis.

Results

Of the 291 patients described above, data on N stage, morphology, radiotherapy dose or tumour length were missing in 25 patients. Therefore, the analysis was conducted on the remaining 266 to ensure a consistent denominator. The distribution of T stage, gender and age in the 25 patients with missing data was very similar to that in the group of 266 patients and overall survival and confidence intervals in all 291 patients were no different to those in the 266 patients with full data.

Of the 266

Discussion

In this series, 266 patients undergoing dCRT for oesophageal cancer had an overall median survival of 20.6 months, with 43.6, 32.9 and 19.5% of patients being alive at 2, 3 and 5 years, respectively, most having been selected for non-surgical therapy because of co-morbidity or locally advanced disease. Even those with T4 disease had a median survival of 15 months, with a 2 year survival rate of 31.9% (95% confidence interval 20.4–43.9). Two year survival in this group without treatment, based

Conclusion

This study, which represents the largest single centre series of dCRT for the treatment of oesophageal cancer, has shown that it is an effective and well-tolerated treatment. Survival rates were similar to those reported in surgical series, supporting the view that dCRT should be considered in all patients, particularly those who are at higher risk from surgery due to co-morbidities and for patients in whom an R0 resection is unlikely. Further research is needed to optimise local and systemic

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