Comparative Effectiveness of Chemotherapy Alone Versus Chemotherapy and Radiation Therapy for Patients with Stage IV Esophageal Cancer

Abstract

1 evidence supporting the use of adjuvant RT for non-rectal colon cancer in the modern chemotherapy era, there are studies that suggest a local control benefit. Given this limited evidence, adjuvant RT in colon cancer is uncommon and quite controversial. Even with T4 disease, NCCN guidelines say only to "consider RT for T4 with penetration to a fixed structure." We believe that this treatment modality is underutilized, particularly in T4 tumors, and seek to determine if there is an underappreciated benefit to adjuvant RT. Due to the limited number of patients with non-rectal, nonmetastatic colon adenocarcinoma who receive post-operative RT, a national cancer treatment database was searched to provide sufficient patient numbers to power a survival analysis. Materials/Methods: A retrospective analysis using the Surveillance, Epidemiology, and End Results (SEER) database from the National Cancer Institute was performed using data up to and including 2015. Patients were included if they met the following criteria: non-rectal colon cancer, AJCC 6 th or 7 th edition T4, AJCC 6 th or 7 th edition M0, who had oncologic resection, and 1st cancer site. Patients were excluded if they had RT prior to or during surgery, or if the sequence of RT relative to surgery was unknown. Using a Cox proportional hazard model, the relative risk of cause-specific mortality for "RT after surgery" versus "No RT" was calculated. Results: 21,789 pts were identified who met the inclusion criteria. Of these, only 1000 received adjuvant RT and 20,683 received no adjuvant RT; 46% were male (52% RT vs. 46% no RT), 46% were age 70 or older (27% RT vs. 47% no RT), and 64% node-positive (53% RT vs. 65% no RT). When comparing RT vs. no RT, after adjusting for sex, age, N stage, and grade, we determined the relative risk of death from any cause was 0.8849 (95% CI: 0.8008, 0.9779) with a p-value of 0.0165. In other words, adjuvant RT decreased the relative risk of death from colon cancer by 11.5% at 5 years. Conclusion: Adjuvant RT is not routinely utilized for definitive treatment of T4 non-rectal colon cancer, but this analysis shows a significant benefit in cause-specific survival that warrants attention. The limitations of conducting a randomized trial and small patient numbers were mitigated with the use of this large database, however, use of chemotherapy, performance status and physician bias were unknown. This data provides impetus for the oncology community to re-evaluate the use of RT in locally-advanced non-rectal colon cancer. With advances in systemic therapy long term survivorship is common and local control with adjuvant RT will play a more profound role in the definitive treatment of resectable T4 colon cancer.

Palliative resection or radiation of primary tumor prolonged survival for metastatic esophageal cancer

“…The role of palliative resection and radiation is not clear for metastatic EC. However, recent studies have indicated that palliative resection or radiation might benefit for survival . Some case reports revealed promising results on long term survival after palliative surgery as well as radiation .…”

“…However, recent studies have indicated that palliative resection or radiation might benefit for survival. [6][7][8] Some case reports revealed promising results on long term survival after palliative surgery as well as radiation. [12][13][14][15][16][17][18] Our results were in accordance with them that patients underwent palliative resection or radiation had prolonged CSS and OS.…”

“…The median survival was 10.8 months for these patients, leading to the conclusion that surgery should not be recommended for stage IV EC . However, some articles revealed better prognosis in patients with stage IV EC after multimodality therapy with palliative resection, and/or radiation, and chemotherapy …”

“…5 However, some articles revealed better prognosis in patients with stage IV EC after multimodality therapy with palliative resection, and/or radiation, and chemotherapy. [6][7][8] The Surveillance, Epidemiology, and End Results (SEER) database provides real-world information on cancer statistics among American population. We aim to explore the value of palliative resection or radiation of tumor in metastatic EC based on the data from SEER database.…”

Chemoradiotherapy Versus Chemotherapy Alone for Advanced Esophageal Squamous Cell Carcinoma: The Role of Definitive Radiotherapy for Primary Tumor in the Metastatic Setting

“…A prospective randomized phase 2 study demonstrated that the CRT was associated with significantly improved median PFS (9.3 vs. 4.7 months, p = 0.021) and median OS (18.3 vs. 10.2 months, p = 0.001) than CT alone ( 18 ). Moreno et al ( 19 ) also suggested that additional RT could derive better survival compared to CT alone with extended 2- and 5-year OS of 6.4% and 2.7%, respectively (p <.001). In a large cohort of 12,683 patients with metastatic EC, Guttmann et al ( 13 ) reported that definitive-dose (≥50.4 Gy) CRT was associated with superior survival compared to CT alone (median OS 8.3 vs. 11.3 months).…”