NEW YORK (Reuters Health) – Tumor stage after neoadjuvant chemotherapy is more important than the initial tumor stage in gauging prognosis after surgery for adenocarcinoma of the esophagus and esophagogastric junction, according to a study from the United Kingdom.
“This study indicates that the established local downstaging effect of neoadjuvant chemotherapy in resectable esophageal adenocarcinoma is also associated with a reduced systemic relapse rate and an overall improvement in survival that is independent of other known prognostic factors,” the investigators say.
“Patients who had downstaging of their primary tumor after chemotherapy had survival comparable to that of patients with equivalent early-stage tumors who did not require chemotherapy,” according to a report by Dr. Andrew R. Davies from St Thomas’ Hospital London and colleagues online July 28 in the Journal of Clinical Oncology.
The research team reviewed data on 584 patients who had surgery for esophageal or esophagogastric junction adenocarinoma at two high-volume centers in London between 2000 and 2010.
Four hundred patients (68%) received neoadjuvant chemotherapy and 44% had tumor downstaging as a result.
Survival was better in patients with downstaged tumors after neoadjuvant chemotherapy (p
Tumor downstaging was the strongest independent predictor of survival after adjusting for patient age, tumor grade, clinical tumor stage, lymphovascular invasion, resection margin status, and surgical resection type (hazard ratio, 0.43).
Patients downstaged by chemotherapy had lower rates of local recurrence (6% vs 13% with no response to preop chemo; p=0.030) and systemic recurrence (19% vs 29%, p=0.027) and improved Mandard tumor regression scores (p
Survival was “strongly dictated” by pathologic stage after neoadjuvant chemotherapy, rather than initial stage, Dr. Davies and colleagues note in their article.
“This indicates that advanced diagnostic staging procedures (e.g., PET-CT, EUS, or magnetic resonance imaging) should be used after neoadjuvant chemotherapy. The major clinical decision-making should be based on this staging rather than the initial staging. The main purpose of the initial staging would be to identify any distant metastases (thus precluding curatively intended treatment) and to provide a baseline from which to compare response to treatment. This would be a novel clinical approach that might improve clinical decision making and survival after curatively intended treatment,” they write.
Reuters Health asked Dr. Tim Kennedy, a surgical oncologist at Montefiore Einstein Center for Cancer Care in New York City, for his thoughts on the study.
He noted that “most people do believe that if patients have good responses to chemotherapy that those patients do better overall and this study supports that.”
Dr. Kennedy also noted that most U.S. centers, including Montefiore, use neoadjuvant chemoradiotherapy in this patient population, based on results of the CROSS trial published in the New England Journal of Medicine in 2012 (http://bit.ly/1uGGD0A).
He said it should also be noted that the JCO study is a retrospective analysis with inherent selection bias, which “limits its utility.”
The study is “important to provoke thought, but at the end of the day, it’s difficult to change clinical decision making from a retrospective review,” Dr. Kennedy told Reuters Health.
Dr. Davies did not respond to request for comment by press time.
By Megan Brooks
