Authors' objectives:

This report was produced at the request of the Direction de la lutte contre le cancer on the recommendation of the Comite de l'evolution des pratiques en oncologie (CEPO). It is a systematic review on the relative efficacy of neoadjuvant chemotherapy, neoadjuvant chemoradiotherapy and chemoradiotherapy without surgery for the curative treatment of cancer of the esophagus and gastroesophageal junction. The results of this review should serve as the basis for a clinical practice guideline to be developed by the CEPO.

Authors' recommendations: This report evaluated the relative efficacy of neoadjuvant chemotherapy, neoadjuvant chemoradiotherapy and chemoradiotherapy alone (without surgery) for the curative treatment of cancer of the esophagus. On the basis of the analysis of the selected studies, AETMIS concludes that:The efficacy of neoadjuvant chemotherapy for improving the survival of patients with squamous cell carcinoma has not been demonstrated. One large trial reported a benefit of neoadjuvant chemotherapy (two cycles of cisplatin and 5-fluorouracil) compared with surgery alone for improving the overall survival of patients with adenocarcinoma in the lower third of the esophagus. This therapy could be a promising option for treating adenocarcinoma, which has been significantly increasing in incidence. However, the meta-analysis of all the studies did not reveal any difference between the two types of treatment.The efficacy of neoadjuvant chemoradiotherapy for improving the overall survival of patients with esophageal cancer has not been demonstrated. The complete histological response rates observed after this treatment suggest that it could contribute to improving disease-free survival. However, there are currently no criteria that would help target patient subgroups likely to show complete histological responses. Three RCTs revealed improved disease-free survival, mostly in patients with squamous cell carcinomas.Moreover, neoadjuvant therapy (chemotherapy or chemoradiotherapy) increases neither complications nor postoperative mortality.The preoperative addition of chemotherapy or chemoradiotherapy must be discussed by expert clinicians in a multidisciplinary meeting, and the decision must take into account the patient's pre-therapy workup, tumour stage, and personal preferences.Data are insufficient to conclude on the superiority of chemoradiotherapy over surgery. Further randomized studies must be conducted to confirm the best choice. Chemoradiotherapy remains the treatment of choice for patients with Stage I, II or III esophageal cancer who are medically unfit for surgery.In the case of localized or locally advanced squamous cell carcinoma of the esophagus and in inoperable patients, the available data do not allow to establish the real impact of chemoradiotherapy on overall survival. Nevertheless, given that concomitant chemoradiotherapy is more effective than radiotherapy for preventing locoregional tumour recurrences and helps shrink tumours, it is a better therapeutic option. It nevertheless increases acute toxicity (grades 3–4). The choice of this option depends on clinicians' expert opinion and must take into account the patient's clinical status. However, if it is decided to use chemoradiotherapy alone, radiotherapy with a conventional radiation method using a standard dose (50.4 Gy) is suggested. Given that there are limited data on adenocarcinoma, these conclusions apply only to squamous cell carcinoma.Quality of life, including dysphagia and performance status, has not been sufficiently investigated.Available data do not allow to select the most effective therapeutic option among the treatments examined in this report. The choice of therapeutic management depends on the tumour's histological type and stage and on the patient's clinical status. It has been established that patients who respond well to neoadjuvant therapy have a better prognosis and better chances of survival. Nevertheless, there are currently no criteria for defining the profile of patients likely to respond to neoadjuvant therapy in order to target them better.

Project Status: Completed

URL for project: http://www.aetmis.gouv.qc.ca/site/phpwcms_filestorage/16ada069623e528a0231f233ef1be99c.pdf

Year Published: 2009

URL for published report: http://www.aetmis.gouv.qc.ca/site/phpwcms_filestorage/1259a47cb144b55e7349541548253e5a.pdf

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Canada

Organisation Name: Agence d'évaluation des technologies et des modes d'intervention en santé

Contact Address: 2021, avenue Union, Bureau 10.083,Montreal, Quebec H3A S29, Canada.Tel: +1 514 873 2563; Fax: +1 514 873 1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: <p>Agence d'Evaluation des Technologies et des Modes d'Intervention en Sante (AETMIS)</p>