|
Editorial
Does postoperative radiation therapy benefit patients with esophageal cancer?
Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD
J Gastrointest Oncol 2010; 1: 70-71. DOI: 10.3978/j.issn.2078-6891.2010.015
|
|
A review article may have several important purposes.
Primarily it can serve as a setting where important data is
collected with a goal of making it easier for physicians’ and
trainees to become expert in an area and make the best
treatment recommendations. However, an outstanding review
article also provides new insight into the proper interpretation
of the mass of available data. Esophageal cancer management
is particularly in need of such a skilled overview as there
are many treatment options but little data to provide real
clarity about the burdens and benefits of the options under
individual clinical circumstances. Jabbour and Thomas are to
be congratulated for not only compiling an enormous amount
of data, but doing this in a refreshing way that provides insight
into the proper management of esophageal cancer (1).
The stated purpose of this review article is primarily to
evaluate the data that applies to radiation therapy in the
postoperative management of esophageal cancer. However,
the authors comprehensively review the many potential
roles of radiation therapy in definitive management of locally
advanced esophageal cancer, whether given definitively,
preoperatively, or postoperatively. The controversy about
adjuvant and neoadjuvant chemotherapy is addressed. This
choice of a comprehensive review of the data contributed
greatly to the value of this review article, allowing context to
be placed on the data related to postoperative therapy, and in
reality to provide a review more comprehensive than the goal
implied by the title of the article.
There are not well done definitive randomized trials to compare the outcome of postoperative therapy against
preoperative therapy in esophageal cancer with modern
staging and modern treatment techniques. In the United
States preoperative therapy is commonly used in studies at
major institutions in cooperative groups and this appears to
have shaped routine clinical practice. The potential value of
preoperative therapy is that adjuvant therapy could be started
immediately targeting any micro metastatic deposits without
allowing time for further growth, and treatment would
not be given until diagnosis and staging is firmly assessed.
In addition, prior to surgery it is thought that the patient’
s may be better able to tolerate aggressive chemotherapy
and radiation as it can start immediately and their physical
and nutritional state has not been burden by the need to
recover from surgery. On the other hand when therapy is
given postoperatively full staging information is available
and patients who have more extensive disease discovered at
the time of surgery may be spared aggressive treatments and
patients with earlier stage of disease than expected may also
not require such treatment.
The review article has several informative and important
tables that provide an over view of the management
of esophageal cancer. In particular, table 1 addresses
preoperative versus postoperative therapy. Information
is provided about the potential pros and cons which is of
significance, and yet no definitive conclusions are prevented
in this review article which is appropriate given the lack
of definitive data. More recently a large randomized trial
published by Macdonald but including mostly gastric cancer
patients and only a small proportion of patients with GE
junction tumors demonstrated a substantial survival benefit
to postoperative therapy(2). Data that might support specific
conclusions about GE junction esophageal tumors was not
provided, likely because an insufficient number of patients
were in this category.
Discussion as to why it is difficult to develop definitive
conclusions about these different approaches may be
appropriate. Certainly, the bias of treating physicians and patients related to use of these very different approaches has
limited randomization. The large size of a trial that designed
to properly establish differences in survival that are likely to
be modest (i.e. the range of 10-15% in long term survival), is
difficult to do in esophageal cancer, a relatively uncommon
tumor. While it would certainly appropriate to close this
article with a routine statement that definitive randomized
data is needed, such information is unlikely in the near
future and this review article actually provides information important to guiding therapy for patients here and now while
studies are done around the world.
|
|
References
Cite this article as:
Kleinberg L. Does postoperative radiation therapy benefit patients with esophageal cancer? J Gastrointest Oncol. 2010;1(2):70-71. DOI:10.3978/j.issn.2078-6891.2010.015
|
