The combination of chemotherapy and radiation for cancer of the esophagus is more effective than radiation alone for patients who do not undergo surgery and whose disease has not spread, according to a large meta-analysis published in Issue 1 (2006) of the Cochrane Database of Systematic Reviews.

“Based on the available data, when a non-operative approach is selected, (combined chemotherapy and radiation) is superior to (radiation therapy alone) for patients with localized esophageal cancer, but with significant toxicities,” wrote the authors, led by Rebecca Wong, MD, of Princess Margaret Hospital in Toronto, Canada.

The review comprised 19 randomized controlled trials including 11,998 patients who were given either both therapies or radiation alone, for an average of five to six weeks.

The survival rate was 5 percent to 12 percent at two years for the combined therapy group compared with 3 percent to 6 percent for patients who received radiation therapy alone. However, the combination treatment group had a 15-percent higher risk of toxic effects from treatment such as gastrointestinal and blood disorders.

Cancer of the esophagus represents 1 percent of all US cancers annually but is responsible for 7 percent of annual cancer deaths. It is estimated that in 2005 there were 14,520 new cases of and 13,570 deaths due to esophageal cancer. The cancer tends to spread rapidly, and only 30 percent of patients have cancer that has not spread. Five-year survival rates range from 5 to 20 percent.
Heavy alcohol use, smoking, and irritation of the esophagus from other disorders can increase risk.

Exactly what treatment patients should receive depends on how much the cancer has progressed and the patient’s overall health, according to Wong. “Patients who have good performance status, no comorbid conditions, and can tolerate surgery better, should be offered surgery” in addition to radiation and chemotherapy, she said. But, she added that combined chemotherapy and radiation alone is the “treatment of choice for patients who are at higher risk for surgery, and potentially for early cancers.”

David Paul Kelsen, MD, chief of gastrointestinal oncology at Memorial Sloan-Kettering Cancer Center, said, “This update confirms a modest but real benefit of (combined chemotherapy and radiation therapy).” Such treatment has been studied since the 1970s, he said, and is used in many types of cancer and is currently a standard of care in several diseases.

“We are clearly getting better at providing this treatment,” Kelsen said. “If the decision is made to provide radiation therapy, chemotherapy should be given at the same time. Better systemic therapy will continue to improve outcomes, but further research is needed.”

Wong agreed that even combination treatment has only a modest effect on survival in patients with esophageal cancer. “Strategies that can enhance local control as well as reducing risk of systemic progression while limiting toxicity are desperately needed for the management of this disease,” she said.