Treatment
Of Esophageal Cancer The problem in reporting evidence based medicine
data regarding the optimal treatment is that the literature is very confusing.
For instance, we know from large series (for instance
a study with about 700 patients from Massachusetts Gen. Hosp., cited on p.783,
Ref. 1) that esophageal cancer occurs in about 25% of patients in the upper third,
in 50% in the middle third and in 25% in the lower third of the esophagus. Most
of the literature, however, does not cite the exact location of the cancer and
therefore we only get general survival data. There are similar problems with cancer
staging as some authors are very precise, even citing the TNM system on top of
the stage I to IV nomenclature, but others only report about a "group that
was seen in their clinic". Most patients already have systemic disease
and the challenge in future is to improve on the cancer survival rate with newer
combination therapies. With esophageal cancer we are not at this point yet. However,
there are trials going on to improve on survival and I will report about some
of this progress. Surgery has been very successful for stage I esophageal
cancer when the cancer is confined to the mucosal lining and does not exceed 5
cm (=2") of local spread. Techniques for this vary, but two standard approaches
are the trans-thoracic approach, where the surgery is done through the opened
chest cage, and the transhiatal approach, where surgery is done through the abdominal
cavity from below. A common approach is the removal of the esophagus (called "esophagectomy")
and replacement of it by the left half of the transverse colon. The mortality
rate of this procedure in the hands of an experienced cancer surgeon is about
7%. Here are the 5-year survival rates with surgery alone for esophageal
cancer:
| 5-year survival rates
for esophageal cancer | | Stage | with
surgery | additional therapy followed
by surgery | | I | 70.5
% | |
| II | 24.5
% | 45 % * |
| III | 12.5
% | 33 % ** |
| IV | 0 % | 5-
10 % * |
| * radiation therapy followed by extensive tumor load
reducing surgery | | ** chemotherapy and radiation
therapy followed by surgery | There seems
to be a concensus that for stage I esophageal cancer surgery alone would be the
treatment of choice, although better survival rates may still be achieved with
with additional radiotherapy or chemotherapy. No clinical trials, however, have
been done to prove this. With stage II esophageal cancer, as can be seen from
the above table, the results are better by about 20 % if radiation therapy is
given first followed by surgery ( 24.5 % versus 45 % ). Similarly, with grade
III esophageal cancer where the cancer has invaded the surrounding structures
and metastasized into the regional lymph glands, the 5-year survivals are superior
with initial chemotherapy and radiotherapy followed by surgery. In this group
of patients there was an improval noticed from 12.5% to 33%. With stage IV the
problem is that the immune system is paralyzed from the cancer and the patients
are so weak and often in poor physical shape that they do not tolerate the toxic
treatments like radiotherapy or chemotherapy. Surgery also has a much higher mortality
rate meaning that most patients are inoperable. |
