Chemotherapy before surgery may help patients with surgically removable esophageal cancer to live longer.

Vogt K, Fenlon D, Rhodes S, Malthaner R

Published Online:

July 7, 2010

Cancer of the esophagus is often not discovered until it is in quite an advanced state. This means that even removing the tumor by surgery is not very successful and many people die within five years. Chemotherapy (cancer fighting drugs such as cisplatin) has been used before surgery to try and shrink the tumor, make it easier to operate on and stop it spreading. Therefore, chemotherapy may help people to live longer. This review of eleven trials, including patients with esophageal cancer of any cell type, found some evidence that cisplatin-based chemotherapy may help them to live longer. However, chemotherapy may increase some side effects.

Abstract (click to read)

Background:

Surgery has been the treatment of choice for localized esophageal cancer. A number of studies have investigated whether preoperative chemotherapy followed by surgery leads to an improvement in cure rates but individual reports have been conflicting. An explicit systematic update of the role of preoperative chemotherapy in the treatment of resectable thoracic esophageal cancer is, therefore, warranted.

Objectives:

The objective of this review is to determine the role of preoperative chemotherapy on patients with resectable thoracic esophageal carcinomas.

Search strategy:

Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to 2009), EMBASE (1988 to 2009) and CANCERLIT (1993 to 2002). We did not confine our search to English language publications. Searches in CENTRAL, MEDLINE and EMBASE were updated in March 2009.

Selection criteria:

All trials of patients with potentially resectable carcinomas of the esophagus (of any histologic type) who were randomized to having either chemotherapy or no chemotherapy before surgery.

Data collection and analysis:

The primary outcome was survival, which was assessed using hazard ratios. This is an amendment to the original review which used relative risks to assess survival at yearly intervals. Hazard ratios (HR) have now been introduced to summarise the complete survival experience in a single analysis. The risk ratio (relative risk; RR) was used to compare rates of resections, tumor recurrences and treatment morbidity and mortality.

Main results:

There were twelve randomized trials involving 2097 patients. Eight trials (1729 patients) reported sufficient detail on survival to be included in a meta-analysis for the primary outcome. There was some evidence to suggests that preoperative chemotherapy improves survival, but this was inconclusive (HR 0.88; 95% CI 0.75 to 1.04)

There was no evidence to suggest that the overall rate of resections (RR 0.96, 95% CI 0.92 to 1.01) or complete resection (RR 1.09, 95% CI 0.98 to 1.20) differs between the preoperative chemotherapy arm and surgery alone. There is no evidence that tumor recurrence (RR 0.81, 95% CI 0.54 to 1.22) or non-fatal complication rates (RR 0.90; 95% CI 0.76 to 1.06) differ for preoperative chemotherapy compared to surgery alone. Trials reported risks of toxicity with chemotherapy that ranged from 11% to 90%.

Authors' conclusions:

In summary, preoperative chemotherapy plus surgery may offer a survival advantage compared to surgery alone for resectable thoracic esophageal cancer, but the evidence is inconclusive. There is some evidence of toxicity and preoperative mortality associated with chemotherapy.

This record should be cited as:

Vogt K, Fenlon D, Rhodes S, Malthaner R. Preoperative chemotherapy for resectable thoracic esophageal cancer. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD001556. DOI: 10.1002/14651858.CD001556.pub2

Assessed as up to date:

January 22, 2010

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Primary Review Group:

Upper Gastrointestinal and Pancreatic Diseases Group

Health topics:

Gastroenterology > Cancer: oesophagus > Treatment

Cancer > Oesophagus

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Chemotherapy before surgery may help patients with surgically removable esophageal cancer to live longer.

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