Treatment of advanced esophageal cancer

Over 90% of patients with epidermoid carcinoma of the esophagus will either present with or will develop advanced incurable disease within five years of diagnosis. The primary goal of therapy for these patients if palliation. A variety of surgical approaches have been used to restore or improve swallowing function. Gastrostomy tubes, dilation, or intraluminal tubes are the simplest procedures but do not usually allow use of a normal diet. More aggressive approaches involving bypass or palliative resection have a substantial morbidity and mortality but dietary intake is more normal. Radiation therapy, given in a palliative fashion, gives substantial relief from dysphagia in only 50% of patients, usually for a 2--6 month period. Although conventional chemotherapeutic agents are of little of no benefit, newer investigational drugs, used in combination, appear substantially more effective. The combination of cisplatin, vindesine, and bleomycin has been noted to induce major objective regressions in 50% of a group of 62 patients with either metastatic or locoregional disease. In patients with disease limited to the locoregional area, resection rates following preoperative therapy with cisplatin-based combination chemotherapy (with or without concommitant radiation) range from 75--85%. Whether the increased response rates seen with newer systemic agents will lead to improved disease-free and total survivals is not yet known.