Debating the Optimal Preoperative Approach: NACRT vs NACT in Locally Advanced Oesophageal Cancer

Oesophageal cancer (EC), ranking 11th in incidence and 7th in mortality globally, presents a significant health challenge, with a notable prevalence in India, especially in the northeastern region. This article examines the efficacy of neoadjuvant chemoradiotherapy (NACRT) versus neoadjuvant chemotherapy (NACT) in treating locally advanced EC, analyzing data from randomized controlled trials (RCTs) between 2000 and 2024. NACRT, involving preoperative chemoradiotherapy followed by surgery, has shown improved survival rates, notably in the CROSS trial, which reported a 10-year overall survival benefit of 13%. Conversely, NACT is supported by key trials like the OE02 and MAGIC trials, demonstrating comparable survival outcomes. Key points of debate include compliance, complications, response and resection status, survival rates, and health-related quality of life (HRQOL). Compliance rates are similar for both modalities, though disease progression is more common after NACT. Postoperative complications and mortality rates are comparable, with NACTRT showing higher pathologic complete response (pCR) and R0 resection rates, potentially avoiding additional adjuvant radiation. While NACRT shows marginally better 3-year survival rates, particularly for squamous cell carcinoma, 5-year survival rates and HRQOL outcomes are similar for both treatments. NACTRT is associated with more respiratory symptoms, whereas NACT patients experience more gastrointestinal issues. Both NACT and NACTRT are viable options, with the choice depending on patient-specific factors and a thorough assessment of potential benefits and risks. Further research is needed to optimize treatment protocols for EC.