Neoadjuvant Therapy for Cancer of the Esophagus

BACKGROUND: The standard of care for esophageal cancer has historically been surgical resection. However, survival following surgical treatment of esophageal cancer remains poor. In inoperable patients, both radiation therapy and chemotherapy alone and in combination have been used with some success. Consequently, these therapies have been utilized in the neoadjuvant setting to improve palliation and prolong survival. METHODS: The author reviewed the literature regarding clinical trials that employed neoadjuvant chemotherapy and radiation therapy in the treatment of squamous cell carcinoma and adenocarcinoma of the esophagus. RESULTS: In most patients, surgery alone is noncurative therapy, even when performed with curative intent. Most phase III trials of neoadjuvant therapy have not been designed with adequate statistical power to detect clinically relevant improvement. The available data are insufficient to determine a benefit to preoperative radiation therapy alone. Preoperative chemotherapy with 5-FU plus cisplatin followed by surgery probably offers little or no improvement over surgery alone. Trials of combined preoperative chemoradiation therapy have yielded promising but not definitive results. CONCLUSIONS: Outside of a clinical trial, neoadjuvant therapy for esophageal cancer should be reserved for only a select group of patients. Future clinical trials may determine a role for neoadjuvant chemoradiation and identify more active chemotherapeutic agents and populations most likely to benefit.