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ASCO GI - Clear Survival Benefits Not Evident
... for Esophageal Cancer Strategies
By Roberta Friedman, PhD
SAN FRANCISCO, CA -- January 23, 2004 -- Two similar retrospective studies presented here today at the First Annual ASCO Gastrointestinal Cancer Symposium gave opposite results for the survival benefits when chemotherapy and radiation precede surgery for esophageal cancer.
The studies, by researchers at Vanderbilt University in Nashville, Tennessee, and at Fox Chase Cancer Center, in Philadelphia, Pennsylvania, found either no, or only some survival advantage for achieving a complete pathologic response to chemoradiation prior to surgery to remove the area of esophagus that had tumor.
"It doesn't mean we would give up on the modality [of shrinking the tumor as much as possible before surgery]," said Carl Schmidt, MD, a resident and research fellow in surgical oncology at Vanderbilt. "There [just is] not as much promise as anyone would have hoped."
Both studies were posters presented at the symposium, which is sponsored jointly by the American Society of Clinical Oncology and other societies. Each was a retrospective review of about 150 patients, with different regimens of chemotherapy and radiation. Dr. Schmidt could not identify any particular factor that would explain the different outcomes, as the study populations were similar in terms of the mix of regimens and the type of cancer.
In both, about a third of patients had a pathologically complete response to chemoradiation. In the Fox Chase study, that one third of patients did better long term than other patients, but this was not the case in the Vanderbilt study.
Slightly longer follow up in the Vanderbilt study may mean that the Fox Chase patients might have started to experience recurrences as they continued surveillance. That is the only possible difference, said Jordan Berlin, MD, senior investigator for the Vanderbilt study. "In these two trials," Dr. Berlin said, "there is no more answer than what we had before."
He noted that the obvious limitation to both is their retrospective nature.
The Vanderbilt study looked at 147 consecutive patients, two thirds with adenocarcinoma, and the rest with squamous cell carcinoma. Of 118 who had chemoradiation prior to surgery, 32% had a complete response as judged by pathology. Yet these patients did not have different rates of overall survival, disease specific survival, or disease free survival. Stage IV patients were excluded. Also no change in 30-day survival or complication rate appeared for patient who had the prior treatment compared to those who had surgery alone.
Median follow up for the Vanderbilt study was 21 months (26 months for survivors).
In the Fox Chase study, 135 of 180 patients (141 with adenocarcinoma) had prior chemoradiation. Pathologic stage 0 or 1 did confer a survival advantage for 93 patients compared to 78 patients who did not respond to the prior treatment. Overall 5 year survival for stage 1 and 0 was 34.1%, and greater than 47.4%, respectively, compared to 15.1% for those not downstaged (P < .022).
"Let's say we were underpowered," Dr. Schmidt said, "you're still talking about a third. In the [other] two thirds, you have not [provided] benefit. We don't have therapy that anyone is happy with, for what we can do for esophageal cancer."