• 7/21/2003
  • Baltimore MD
  • Shalmali Pal
  • The International Journal of Radiation Oncology, Biology, and Physics

The standard of care for the treatment of esophageal cancer advanced
significantly at the close of the 20th century, including the increased use
of esophageal ultrasound and a combination of chemoradiation and surgery.

“These changes reflect a continual progression of technology into routine
clinical practice, as well as a wider acceptance of the results of large
randomized trials supporting the role of combined-modality therapy in the
management of this disease process,” wrote lead author Dr. Mohan
Suntharalingam from the University of Maryland School of Medicine in
Baltimore in the International Journal of Radiation Oncology, Biology, and
Physics (July 2003, Vol. 56:4, pp. 981-987).

The paper compared the latest trends in treatment and care to earlier data
from the nationwide Patterns of Care Study (PCS). The latter was started in
1971 in an effort to improve the quality and accessibility of radiation
oncology in the U.S. The present retrospective study was designed to
evaluate patients who received radiotherapy for esophageal cancer from 1996
to 1999 and compare these numbers to PCS data obtained between 1992 and
1994.

Suntharalingam’s co-authors are from the American College of Radiology and
the University of Pennsylvania, both in Philadelphia; the Community Medical
Center in Toms River, NJ; Boston University School of Medicine and
Massachusetts General Hospital in Boston; the Cancer Center at St. Agnes in
Fresno, CA; and Memorial Sloan-Kettering Cancer Center in New York City.

For this study, site visits took place at 20 large academic centers, 19
large nonacademic centers, and 20 small academic facilities. Data for a
total of 414 patients were deemed eligible. The majority of the patients
(77%) were male and Caucasian (75%). Half were identified as having
adenocarcinoma. Only 16% were stage I, according to the American Joint
Committee on Cancer (AJCC) guidelines.

In 96% of the cases, endoscopy was used for pre-treatment evaluation. CT
scans of the chest were obtained in 87% of cases; abdominal CT in 75%.

“The use of esophageal ultrasound (EUS) increases significantly during the
period studied as compared to the initial PCS survey (18% versus 2%),” the
authors wrote. “Patients treated at a large center were more likely to
undergo EUS than those treated at a small center (23% versus 12%).”

More than half of the patients (56%) received concurrent chemoradiation as
their definitive treatment plan. In 27% of the cases, surgical resection was
planned after neoadjuvant chemoradiation. Once again, the authors found an
increase in preoperative chemoradiation followed by surgery in their data
(27%) when compared with the previous PCS survey (10%), most often in
patients with adenocarcimona.

All patients received external-beam radiation therapy with a medial total
dose of 50.4 Gy delivered. The majority of patients (93%) completed the full
course of radiotherapy (50 days or more). Ninety-seven percent of the
patients received concurrent chemotherapy, including 5-fluorouracil (82%),
cisplatin (67%), and paclitaxel (22%).

The authors pointed out that there has been a significant increase in the
use of paclitaxel (22% in this study versus 0.2% in the PCS study), despite
the lack of phase III data. They attributed paclitaxel’s popularity to the
“desire to improve local control and overall survival associated” with
more-established chemotherapy drugs.

Finally, they found that patients treated at large facilities were more
likely to undergo 3-D CT treatment planning than patients at smaller
institutions.

“(These) results will be shared with investigators from the American College
of Surgeons, along with researchers from various other countries…in an
attempt to identify possible opportunities to improve the outcomes for this
patient population,” they concluded.