4/24/12 Medical News: Survival Rates for Esophageal Cancer Climb

4/24/12 Medical News: Survival Rates for Esophageal Cancer Climb ‐ in Oncology/Hematology, Other Cancer...
Survival Rates for Esophageal Cancer Climb
By Neil Osterweil, Senior Associate Editor, MedPage Today
Published: April 13, 2006
Reviewed by Robert Jasmer, MD; Assistant Professor of Medicine, University of California, San Francisco .
ROCHESTER, N.Y., April 13 ­ Misperceptions about morbidity and survival rates following surgery for esophageal cancer may be unwisely turning some patients away from an esophagectomy, according to surgical oncologists.
Action Points
Explain to interested patients that a combination of earlier detection of esophageal cancer at a more treatable stage and a shift from squamous­ cell types to adenocarcinomas has resulted in improved five­year survival rates following esophagectomy.
"Those who argue against surgery for
esophageal cancer cite surgical mortality
rates of up to 15% and low five­year
postoperative survival rates of 20% to justify
their approach," said Jeffrey H. Peters, M.D., of the University of Rochester (N.Y.) Medical Center.
"What's worrying is that treatment decisions are being made based on decades­old experiences with a type of esophageal cancer that most patients no longer have, and on fears about problems with surgery that are no longer a concern," Dr. Peters said.
He was co­author of a study published in the April issue of the Journal of the American College of Surgeons which found that five­year survival after esophagectomy is close to 50%, and is better than that reported for any other form of therapy.
"This emphasizes the central role of surgery in the treatment of this disease," he and colleagues wrote. "Resection can be accomplished with low mortality and acceptable morbidity."
They cited changes in epidemiology, the development of endoscopic surveillance programs, and the liberal use of endoscopy that provide an opportunity to detect tumors at an earlier stage when the five­year survival following surgery exceeds 80%. "Long­term survival following non­surgical treatment should be compared to these outcomes," they asserted.
Dr. Peters and colleagues said that those who advocate neoadjuvant chemotherapy and radiation therapy in lieu of surgical resection are missing the bigger picture, namely that there has been a significant shift in histologic type and location of esophageal tumors over the past several decades.
According to the National Cancer Institute, the incidence of esophageal cancer has risen in recent decades, and this increase has coincided with a shift away from squamous­cell carcinomas of the esophagus to esophageal adenocarcinoma, possibly related to Barrett's esophagitis and gastroesophageal reflux disease.
Surgery for esophageal adenocarcinomas can produce higher five­year survival rates with acceptable functional results, but those who question the utility of surgery are basing their opinions on older experience with more refractory late­stage squamous cell carcinomas, the authors argued.
"This encourages acceptance of the concept that surgical therapy is no longer central in the treatment of esophageal carcinoma because the survival benefits are outweighed by the risks of resection," the authors wrote.
To get a more accurate picture of outcomes for patients treated with esophagectomy for adenocarcinoma, they studied 263 consecutive patients (215 men and 48 women) who underwent the procedure from 1992 to 2002. In all, 37% of the patients had stage I disease, 24% had stage II, 35% had stage III and 4% had stage IV adenocarcinoma.
"Interestingly, 51% (131 of 263) of the patients presented with a primary symptom other than dysphagia," the investigators wrote. "When dysphagia was present, the patient was significantly more likely to have advanced disease. The liberal use of endoscopy for surveillance of Barrett's esophagus detected patients at an earlier stage of disease compared to those presenting for other reasons."
Curative en­bloc resection was performed in 45% of the patients, 52% had node involvement, and 18% received neoadjuvant therapy. In all, 38% of patients had an uncomplicated postoperative course.
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4/24/12 Medical News: Survival Rates for Esophageal Cancer Climb ‐ in Oncology/Hematology, Other Cancer...
Deaths in the hospital or within 30 days of surgery occurred in 4.55% of patients. Two patients died from pulmonary embolism, two died from respiratory causes, two had, multisystem organ failure, three had graft ischemia and one suffered a fatal cardiac arrhythmia. There were no differences in 30­day mortality rates between the two surgical approaches used (transhiatal or en bloc esophagectomy).
Among all patients, 18% had more than one complication, with pneumonias, cardiac arrhythmias, and anastomotic leaks occurring most commonly. Thirteen percent of patients required a second operation.
The survival analysis showed that the median survival was in excess of four years. Five­year survival was 46.5% (95% CI 31.8%­61.3%), and among those patients who were treated during the last five years of the study it was 50.4%.
Five­year survival among patients who did not have nodal metastases was 73%. Among those patients with any degree of nodal involvement, survival was significantly better when the ratio of involved nodes to the total number of nodes removed was less than 10% (P<0.0001). Patients with all disease stages who underwent en­bloc resection had a significantly better survival rate than those who underwent transhiatal resections (P=0.0003).
Cancer was the cause of death after en­bloc resection in 13.3%, and after transhiatal resection in 18.2% of patients .The overall five­year survival by stage was 81% for stage I, 51% for stage II, 14% for stage III, and 9% for stage IV.
When the authors performed a Cox proportional hazard analysis, they found that tumor stage and type of resection were independent predictors of survival.
"The five­year survival of nearly 50% that we report stands in stark contrast to the 20% commonly quoted," the investigators wrote. "The increasing number of patients with early stage disease no doubt accounts for a significant portion of the improved survival."
They attribute the shift toward diagnosis of esophageal cancer at earlier stages to improved surveillance for Barrett's esophagus, and changes in endoscopy practice favoring earlier detection.
"Given the fact that we are now detecting tumors at an earlier stage, when the survival is substantially better, it is surprising we are still arguing about whether creating a surveillance system to catch patients early is worth the cost of the tests," Dr. Peters said. "Once we catch a tumor early, surgeons and oncologists need to come together to craft treatment approaches that act on state­of­the art information to cure more patients."
Primary source: Journal of the American College of Surgeons
Source reference:
Portale G et al. "Modern 5­Year Survival of Resectable Esophageal Adenocarcinoma: Single Institution Experience with 263 Patients." J Am Coll Surg. 202;4:588­96
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