Neoadjuvant CRT plus surgery improves survival in oesophageal cancer

Oesophageal cancer patients treated with neoadjuvant chemoradiation (NACRT) plus surgery have better overall (OS) and disease-free survival (DFS), but careful selection of patients is needed to lessen perioperative risks, suggest the results of a Singapore study.

“With the predominant histology of our cohort being squamous cell carcinoma (SCC), results from our study may be more relevant for SCCs within the Asian population,” the researchers said.

A retrospective review was conducted on oesophageal patients who underwent chemoradiotherapy (chemoRT) from 2005 to 2017. The researchers then reported outcomes (primary: OS; secondary: DFS and toxicities) of those treated with NACRT plus surgery or definitive chemoRT.

Ninety-six patients (median age 64 years) with SCC were identified, of whom 29 (30.2 percent) received NACRT plus surgery and 67 (69.8 percent) definitive chemoRT. Median follow-up was 13.5 months. [Ann Acad Med Singap 2021;50:536-547]

The 3- and 5-year OS rates were 26.4 percent and 13.4 percent in the definitive chemoRT group and 59.6 percent and 51.6 percent in the NACRT plus surgery group, respectively. In terms of DFS, the corresponding 3- and 5-year rates were 19.3 percent and 12.3 percent in the definitive chemoRT arm and 55.7 percent and 37.2 percent in the NACRT plus surgery arm.

Treatment with NACRT plus surgery resulted in significant improvements in OS (hazard ratio [HR], 0.40, 95 percent confidence interval [CI], 0.22–0.72; p<0.01) and DFS (subhazard ratio [SHR], 5.21, 95 percent CI, 1.20–22.7; p=0.03).

In multivariable analysis, indicated stage (1–2 vs 3–4a: HR, 2.17, 95 percent CI, 1.15–4.11; p=0.02) and feeding tube (no tube vs tube: HR, 1.85, 95 percent CI, 1.00–3.43; p=0.05) were significantly associated with OS in the definitive chemoRT group.

Moreover, the cumulative incidence of local recurrence was markedly greater among patients in the definitive chemoRT arm (SHR, 5.21, 95 percent CI, 1.20–22.7; p=0.03). Of note, postoperative complications occurred in 19 patients (65.5 percent).

These findings supported those from other retrospective studies reporting better survival with NACRT plus surgery. NACRT plus oesophagectomy also led to improved outcomes compared with definitive chemoRT in oesophageal cancer patients. [World J Surg Oncol 2018;16:141; J Gastrointest Surg 2020;24:1937-1947; Ann Surg 2002;236:376-385]

“However, not all studies have reported benefit in OS with NACRT plus surgery,” the researchers said, noting a Cochrane systematic review which found that adding oesophagectomy only provided little or no difference in OS and might even result in higher treatment-related mortality. [Cochrane Database Syst Rev 2017;8:CD010511]

The present study was limited by its retrospective nature and relatively small sample size, most of whom had SCC. Selection bias might also have occurred, in which surgery was carried out on fitter patients. Additionally, being a nonrandomized study, confounders might not have been accounted for, and reviewer bias could have led to under-reporting of treatment toxicities.