Palliative radiotherapy: No added benefit for individuals with advanced oesophageal cancer

Apart from reducing bleeding risk in individuals with advanced oesophageal cancer (ESCA) who had self-expanding metal stent (SEMS) insertion to improve dysphagia, concurrent palliative radiotherapy (RT) does not reduce recurrent dysphagia nor does it improve overall survival (OS), findings from the phase III ROCS* study have shown.

Most patients with advanced ESCA will require intervention for dysphagia and have limited treatment options and a poor prognosis. [Gastrointest Endosc Clin N Am 1998;8:451-463; J Thorac Oncol 2012;7:443-447] Although SEMS insertion may offer rapid dysphagia relief, its efficacy is confounded by post-insertion issues** that consequently impact quality of life (QoL). [Cochrane Database Syst Rev 2009;4:CD005048; Cochrane Database Syst Rev 2014;10:CD005048]

Hospitalization and re-intervention following insertion is not uncommon, raking in additional costs. These impose a significant burden on both resources and a vulnerable patient group. Combining SEMS with other therapies may reduce this burden, the researchers noted. “[Our findings suggest that adjuvant] RT after SEMS insertion does not reduce dysphagia deterioration and adds significantly to the cost of treatment.”

The team compared the efficacy of adjuvant RT with UC in 220 individuals with incurable ESCA***. Participants were randomized 1:1 to receive usual care (UC), either alone or with external beam radiotherapy (EBRT) after SEMS insertion. [Lancet Gastroenterol Hepatol 2021;6:292-303]

No significant difference was seen between the EBRT and the UC arm in terms of the percentage of participants with dysphagia deterioration up to 12 weeks (45 percent vs 49 percent; adjusted odds ratio, 0.82; p=0.59) or median OS (18.9 vs 19.7 weeks; adjusted hazard ratio, 1.06; p=0.70).

Cost-utility analysis showed a higher total cost of care per patient tied to the EBRT vs the UC arm (£6,500 vs £4,668; p=0.013). Mean EBRT cost per patient was £1,297, which accounts for the substantial difference in total mean cost of £1,832 in favour of UC.

Median time to first bleeding event or hospital admission for a bleeding event was longer with EBRT vs UC (65.9 vs 49.0 weeks; adjusted subhazard ratio, 0.52; p=0.038). “[This] suggests that RT could be considered for a minority of patients deemed at increased risk of tumour bleeding rather than for all patients, to minimize bleeding risk and the need for associated interventions,” said the researchers. “[However, this] warrants further investigation.”

Should NOT be routinely recommended

“[We] developed ROCS in response to a UK NIHR^# call for research proposals into aspects of palliation, and aimed to address uncertainties in the evidence base for interventions combined with SEMS,” said the researchers.

“[Our findings] show that when stent insertion is required to palliate dysphagia, most patients will not additionally benefit from locoregional RT … This should not be routinely offered,” they stressed. Despite its benefit for patients with high bleeding risk, this should be carefully weighed against its risks, they pointed out.

“Most [ESCA] patients present with incurable disease … Our study highlights the considerable unmet needs of this patient group. We hope our findings will challenge upper gastrointestinal services to establish better evidence in this field on other combination therapies and how multidisciplinary support can help patients and families negotiate symptom burden and improve QoL,” they concluded.