Relief of dysphagia during neoadjuvant treatment for cancer of the esophagus or gastroesophageal junction

Abstract

Dysphagia is the main symptom of cancer of the esophagus and gastroesophageal junction and causing nutritional problems and weight loss, often counteracted by insertion of self-expandable metal stents or nutrition via an enteral route. Clinical observations indicate that neoadjuvant therapy may effectively and promptly alleviate dysphagia, making such nutrition supportive interventions redundant before surgical resection. The objective of the current study was to carefully study the effects of induction neoadjuvant therapy on dysphagia and its subsequent course and thereby investigate the actual need for alimentary gateways for nutritional support. Thirty-five consecutive patients scheduled for neoadjuvant therapy were recruited and assessed regarding dysphagia and appetite at baseline, after the first cycle of preoperative treatment with either chemotherapy alone or with chemoradiotherapy and before surgery. Platinum-based therapy in combination with 5-fluorouracil was administered intravenously days 1-5 every 3 weeks and consisted of three treatments. Patients receiving combined chemoradiotherapy started radiotherapy on day one of second chemotherapy cycle. They received fractions of 2 Gy/day each up to a total dose of 40 Gy. Watson and Ogilvie dysphagia scores were used to assess dysphagia, while appetite was assessed by the Edmonton Assessment System Visual analogue scale-appetite questionnaire. Patients were evaluated at regular outpatient clinic visits or by telephone. The histological tumor response in the surgical specimen was assessed using the Chirieac scale. Ten patients scheduled for neoadjuvant chemotherapy and 25 patients scheduled for chemoradiotherapy were included in the analysis. There was a significant improvement in dysphagia in both treatment groups, according to both scales, already from baseline to the completion of the first chemotherapy cycle which remained to the end of the neoadjuvant treatment (P < 0.001). Appetite also improved after the first chemotherapy cycle (P = 0.03). Body weight did not change during any type of neoadjuvant therapy. We were unable to demonstrate any association between relief of dysphagia and the degree of histological response to neoadjuvant therapy in the surgical specimen. The present study shows that a platin - 5FU-based neoadjuvant chemotherapy, with or without concomitant radiotherapy, effectively and promptly relieves dysphagia in patients presenting with cancers of the esophagus or gastroesophageal junction already after the first cycle.

Enteral Access is not Required for Esophageal Cancer Patients Undergoing Neoadjuvant Therapy

“…Reports of clinically significant improvement in dysphagia with neoadjuvant treatment identified the feasibility of preserving nutrition without EA [13,14,33]. Sunde and colleagues [14] demonstrated that significant relief could be observed with the first treatment of a platinum-based therapy in combination with 5fluorouracil and radiotherapy.…”

“…Reports of clinically significant improvement in dysphagia with neoadjuvant treatment identified the feasibility of preserving nutrition without EA [13,14,33]. Sunde and colleagues [14] demonstrated that significant relief could be observed with the first treatment of a platinum-based therapy in combination with 5fluorouracil and radiotherapy. Similar results were achieved by Cools-Lartigue and colleagues [13] in Toronto, with taxotere, cisplatin, and 5-fluorouracil (TCF), epirubicin, cisplatin, and 5-fluorouracil (ECF), or docetaxel, oxaliplatin, leucovorin, and 5-fluorouracil (FLOT) demonstrating improvement of dysphagia after the first cycle.…”

“…Each of these interventions has its own associated adverse event [6][7][8][9][10][11]. Although esophageal cancer patients are at risk for the development of malnutrition, particularly those undergoing neoadjuvant treatments, not all patients require support with enteral feeding access (EA) [10][11][12][13][14]. Neoadjuvant therapy has the potential to reduce dysphagia symptoms and may obviate the need for surgical EA for selected patients [13][14][15].…”

“…Although esophageal cancer patients are at risk for the development of malnutrition, particularly those undergoing neoadjuvant treatments, not all patients require support with enteral feeding access (EA) [10][11][12][13][14]. Neoadjuvant therapy has the potential to reduce dysphagia symptoms and may obviate the need for surgical EA for selected patients [13][14][15]. Recent literature reports suggest that patients can experience significant relief from dysphagia when they complete the first cycle of a platinum-based chemotherapy [14].…”

“…Neoadjuvant therapy has the potential to reduce dysphagia symptoms and may obviate the need for surgical EA for selected patients [13][14][15]. Recent literature reports suggest that patients can experience significant relief from dysphagia when they complete the first cycle of a platinum-based chemotherapy [14]. The objective of this study was to determine whether routine enteral feeding tube placement improved nutritional status and perioperative outcomes for patients undergoing neoadjuvant therapy for esophageal cancer.…”