NIJMEGEN, The Netherlands--With 12,000 new cases of esophageal
cancer diagnosed every year in the United States, and 5-year postoperative
survival rates still hovering under 20%, the need to develop more
effective multimodality treatment strategies remains crucial,
said David Ilson, MD, of Memorial Sloan-Kettering Cancer Center.
Of the three most extensively explored approaches--preoperative
radiotherapy, preoperative chemotherapy, and chemotherapy plus
radiotherapy prior to or instead of surgery--preoperative radiotherapy
has had the least impact on survival, notwithstanding improved
local control, Dr. Ilson said in a presentation at the Sixth EORTC
Gastrointestinal Tract Cancer Cooperative Group symposium.
On the other hand, although preop-erative chemotherapy only rarely
pro-duces pathologic complete responses, it has yielded clinical
response rates in the neighborhood of 50%, exerts no adverse influence
on surgery, and has been associated with a trend toward improved
survival, he said.
Still more promising may be intensified approaches that combine
chemotherapy and radiotherapy, Dr. Ilson said. Surveying phase
II trials of 5-fluorouracil (5-FU)- or mitomycin (Mutamycin)-based
regimens coupled with radiation doses of 3,000 to 6,000 cGy, he
pointed to pathologic response rates as high as 20% to 30% and
to 5-year disease-free survival rates reaching 35% to 40% in some
Unfortunately, he said, preliminary results from a small University
of Michigan trial have shown no differences in survival between
surgery alone vs presur-gical 5-FU, cisplatin (Platinol), and
vinblastine plus 4,500 cGy of radiation. Similarly, in an EORTC
trial, the combined modality approach appeared to offer no survival
advantage over surgery alone.
"Although the pilot studies of preop-erative chemotherapy,
with or without radiation, are very encouraging in terms of response
and trends in survival," he said, "these approaches
remain investigational and need to be validated in the context
of controlled phase III studies."
In the nonsurgical setting, he said, chemotherapy and radiation
are the definitive treatment, "and we can conclude that they
are superior to radiation alone."