Neoadjuvant chemoradiation versus chemotherapy for patients undergoing esophagectomy for esophageal cancer

Neoadjuvant chemoradiation followed by esophagectomy is currently the standard of care for locally advanced esophageal cancer. This intense preoperative regimen delays definitive resection and increases perioperative risks. With the improvement of chemotherapy agents, chemotherapy alone may be better suited for patients awaiting esophagectomy because of shorter preoperative treatment time and less associated perioperative complications. No recent study has compared chemoradiation to chemotherapy alone before esophageal resection with respect to operative morbidity and mortality and overall survival.

A retrospective review was performed of all patients (281) who underwent an esophagectomy for cancer at our institution from July 1995 through June 2005; 122 patients (43%) had neoadjuvant treatment and form the basis of this study.

Preoperative chemoradiation (CR) was administered in 64 patients and chemotherapy only (CO) in 58 patients. Operative mortality was 6% (4 patients) in the CR group and 0% in the CO group (p = 0.12). Overall postoperative complications rate was 48% in CR patients and 33% in CO patients (p = 0.09). Complete pathologic response occurred in 11 CR patients (17%) and in 2 CO patients (4%; p = 0.02). There was no difference in recurrences between the two groups (p = 0.43). Median survival was 17 months in the CR patients and 21 months in the CO patients (p = 0.14). One-, 3-, and 5-year survivals were 76%, 46%, and 41%, respectively, in the CR patients and 70%, 40%, and 31%, respectively, in the CO patients (p = 0.31).

Although neoadjuvant chemoradiation resulted in a significantly better complete pathologic response rate when compared with chemotherapy alone, that did not translate into a long-term survival advantage. Chemotherapy alone may be the preferred neoadjuvant modality to expedite resection, decrease operative mortality and postoperative complications, and improve survival in patients with locally advanced esophageal cancer.