Combined modality therapy of esophageal cancer--standard of care?

Because of the controversies and conflicting data described above, it is very difficult to provide strict guidelines for the treatment of patients with locoregional esophageal carcinoma. It is necessary, however, to try to put current knowledge in perspective. Surgery remains a standard of care for potentially resectable disease. Definitive chemoradiation is a standard of care for locoregional disease, particularly if a patient is medically unfit for surgery, if a surgeon experienced in esophagectomies is unavailable, or if the patient has cervical disease, which would require very extensive surgery. Chemoradiation is superior to radiation alone for these patients. Some frail patients may only be able to tolerate palliative radiation. Preoperative chemotherapy is controversial, with two large randomized studies resulting in two different conclusions regarding survival benefit. NCCN guidelines do not suggest this modality as a standard of care. After assessment of the patient's tumor stage, performance status, and personal wishes for aggressive treatment, it is possible that some physicians may consider offering this option to patients. The patient should have advanced disease, an excellent performance status, and understand the controversies and lack of consensus about this option. Preoperative chemoradiation is controversial. Only one of three randomized trials showed a clear survival benefit; however, the patients treated with surgery alone in that trial had an unusually poor outcome. The second trial showed no benefit, and the third trial was negative but statistically powered only to reveal a large survival difference and in multivariate analysis showed a possible trend to improved outcome. The NCCN guidelines do not advocate preoperative chemoradiation as a standard of care. As stated above, however, some physicians may consider offering this option to patients with advanced disease, excellent performance status, and who understand the controversies and lack of consensus about this option. Patients with adenocarcinoma of the GE junction treated with surgery alone should have postoperative chemoradiation, particularly if there is tumor involvement in the lymph nodes. No definitive trial has been performed to determine whether chemoradiation plus surgery is superior to chemoradiation alone.