Whether surgery, chemotherapy, radiation, or some combination of them should be the standard of care has been debated for years. Until recently, surgery has been considered the gold standard, but its role has been questioned by some medical oncologists based on their assumption that surgery comes with a high risk of complications and small chance of survival. In many cases today, oncologists will try chemotherapy and radiation first, completely avoiding surgery. Authors of the current study argue that the information used to make those decisions is dated, and that the surgery is the most effective approach in many patients.
"Those who argue against surgery for esophageal cancer cite surgical mortality rates of up to 15 percent and low five-year postoperative survival rates of 20 percent to justify their approach," said Jeffrey H. Peters, M.D., Chair of the Department of Surgery at the University of Rochester Medical Center (URMC) and Surgeon-in-chief of Strong Memorial Hospital. "What's worrying is that treatment decisions are being made based on decades-old 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. Our study found that the five-year survival of patients after surgical resection for esophageal adenocarcinoma is better than that reported for any other form of therapy," said Peters, co-author of the journal article.
Changing Face of Esophageal Cancer
In the past, the typical esophageal cancer patient had the kind of cancer caused by smoking (squamous cell carcinoma) and was frequently terminal. Patients needed surgery to make swallowing easier in the time they had left. Today, the average patient is younger, diagnosed earlier with a different kind of cancer (adenocarcinoma) and more likely to be cured.
The shift toward earlier diagnosis of esophageal cancer can be explained by the relationship of adenocarcinoma to gastroesophageal reflux disease (GERD). At the point where the esophagus empties into the stomach, a ring of muscle keeps stomach acid used in digestion from flowing back up into the esophagus. For many people, the ring malfunctions consistently over time, allowing acid to irritate the cells lining the esophagus, which causes "heartburn" pain and GERD. Acid can also cause long-term changes in the esophageal cells that make them pre-cancerous, with the patches of abnormal cells known as Barrett's esophagus.
About 20 million Americans experience severe heartburn. Of those people with frequent heartburn for five years or more, about one in five develop Barrett's esophagus, giving them a 40-fold higher than normal risk of developing GERD-associated adenocarcinoma. While most cancer rates are falling, esophageal cancer has increased dramatically in recent years to become the fastest-growing type in the United States. The trend is likely to worsen as Americans gain more weight.
The increasing prevalence of GERD has resulted in the establishment of Barrett's surveillance programs and the increasing likelihood that a given patient with severe heartburn will undergo endoscopy, an imaging test that can catch cancer early. The combination of the rise in GERD, the drop in smoking, and better diagnostics means that esophageal cancer is often found earlier, and increasingly, while still confined to the esophagus. These patients are the best candidates for surgery to completely remove the tumor and cure it.
A Better Surgery
Along with younger patients with less advanced cancer, better surgery is contributing to longer survival, according to the new study. Statistical analysis of patient survival found that en bloc esophagectomy, an operation that completely removes the cancer along with nearby lymph nodes, results in 30 percent fewer cancer deaths than a transhiatal resection, a surgery that leaves the lymph nodes in place. Researchers believe en bloc resection is more effective because it has a better chance of completely removing the cancer to control the disease at the tumor site.
While still controversial, the authors argue that their results add to a growing body of evidence that removing the lymph nodes, while not helpful in breast cancer, does indeed improve survival rates in esophageal, gastric and rectal cancer. Refinements in operative technique and postoperative care have made en bloc resection much safer as well, researchers said.
While more effective, en bloc resection is used less often used due to its complexity, and the training involved. Based on the current study, medical center researchers are calling for more widespread use of the technique, particularly in those whose tumor is detected early.
The study also found that the number of patients with esophageal cancer now receiving chemotherapy and radiation more than doubled during the ten years during which data was examined, despite a lack of evidence supporting improved survival. One past study found that radiation and chemotherapy are not beneficial in early stage cancer, and may indeed harm patients when side effects are taken into account. Researchers say future work will need to compare survival in patients receiving nonsurgical treatment to survival in patients who have had surgery.
In the current study, researchers reviewed the medical records of 263 patients who underwent esophagectomy for adenocarcinoma between January 1992 and December 2002. Ninety-seven (37 percent) had cancer in stage I, 63 (24 percent) were stage II, 93 (35 percent) were stage III, and 10 (4 percent) were stage IV. The cancer had spread into nearby lymph nodes in 52 percent (138 of 263) of the patients and Barrett's esophagus was identified in 62 percent (163 of 263) of patients.
Forty-five percent of study patients had undergone en bloc resection and 18 percent had received neoadjuvant therapy. Seventeen percent of the patients were identified in a Barrett's surveillance program. During the course of the study period, the percentage of patients presenting with early adenocarcinoma has increased over time, and in the last 2 years, has represented about 50 percent of all resected tumors, researchers found.
The overall 5-year survival was 46.5 percent, and for the last 5 years of the study was 50.4 percent. The overall 5-year survival for stage I was 81 percent; for stage II, 51 percent; for stage III, 14 percent; and for stage IV, 0 percent, reinforcing the importance of early detection. Complications occurred in 61 percent of patients and there were 12 deaths related to surgery.
"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," Peters said. "Once we catch a tumor early, surgeons and oncologists need to come together to craft treatment approaches that act on state-of-the art information to cure more patients."
Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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