In search of better ways to treat patients with esophageal cancer, University of Colorado Cancer Center member Martin McCarter, MD, is investigating whether a new treatment sequence will lead to better outcomes.
While awaiting the results of a group of clinical trials, including one at the CU Cancer Center, McCarter and other researchers at the University of Colorado (led by surgery resident Bobby Torphy, MD, Ph.D.) examined data from the National Cancer Database to see if they could identify other patients who have undergone the new sequence and what the outcomes of those patients were. The group published an article in the Annals of Surgical Oncology in April detailing his findings.
We sat down with McCarter, a professor of surgical oncology at the University of Colorado School of Medicine, to discuss the data and the next steps in his research.
A: The overall picture is that esophageal cancer outcomes remain very poor, even in patients who may undergo surgery and we are constantly looking for ways to improve it. The current standard of care is a combination of chemotherapy and radiation administered together, followed by surgery. Sequencing of treatment has evolved in other areas, particularly rectal cancer, in what is known as a “total neoadjuvant approach,” in which patients receive prolonged chemotherapy, followed by radiation therapy, and then surgery. They have been doing this in rectal cancer and this has led to some improvements in cancer outcomes. Data on this approach to esophageal cancer are limited, but it would make sense in our minds to try it. There are a couple of early-stage trials that look at this sequence to see if it can help improve things for esophageal cancer patients, including a study initiated by a researcher here at CU led by a member of the Cancer Center. CU, Jeffrey Olsen, MD. These trials will take a few years to mature, but in the meantime, we wanted to examine a large national database to see if we could determine if other people have used this sequence. We used the national cancer database to ask this question and found that about 5% of patients received this prolonged sequence. According to the data, it appears that patients have a better survival rate than patients who only receive chemotherapy and radiation before surgery.
Q: How does the proposed sequence differ from the current standard of care?
A: The current standard is for patients to receive five weeks of radiation and to receive some chemotherapy at the beginning and middle of this radiation therapy. Then they wait six or eight weeks and then have surgery. This new approach adds chemotherapy for two or three months first, then moves on to chemotherapy and radiotherapy, and then to surgery. The idea behind it is that, in general, people do not die from local cancer; they die of cancer that has spread microscopically even before we see it. If we first treat them aggressively with chemotherapy, we first attack the microscopic disease and then try to control the local disease with radiation and finally also with surgery.
Q: Is it easy to determine from the data if anyone has undergone this treatment sequence?
A: It is not. We had to make some assumptions and make some pretty meaningful models to answer the question. These determinations were based on the dates in the database and the fact that patients obtained pure chemotherapy, followed by pure radiation, and then had surgery. They had to have these three things, and then they had to separate the dates enough so that they would not receive standard chemotherapy and radiation followed by surgery. The problem is that we don’t really know, just from the data, why they got chemotherapy first. Maybe the doctors made some of the same assumptions we made, meaning that we should hit them hard first, but they did so without a lot of guidance or testing.
Q: Could you use this approach to eliminate the need for surgery in patients with esophageal cancer?
A: Without a doubt, this is the direction things have taken in rectal cancer. People are less likely to avoid surgery esophageal cancer just because surveillance techniques are quite inadequate. We know that several patients are likely to have a complete response to chemotherapy and radiation and do not need intervention; the problem is that we can’t really predict who those patients are, even with our best areas and diagnostic scans.
Q: What is the next step in this research?
A: The next step is to wait for the formal results of the current trial. As a phase 2 trial, the potential toxicity of the use of this sequencing is being evaluated, but also the responses are being evaluated. Do we see better pathological responses and, in the long run, are there patients who do not need esophageal surgery, or for those who do have esophageal surgery, do we see improvements in overall five-year long-term survival? This data study served to set the table and see if we can learn more about this sequencing strategy, because at the moment we have very little to do.
Felix Ho et al., Neoadjuvant induction chemotherapy and chemoradiation for adenocarcinoma of the esophageal and gastroesophageal junction, Annals of Surgical Oncology (2021). DOI: 10.1245 / s10434-021-09999-5
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Citation: Investigate a better treatment sequence for esophageal cancer (2021, June 22) retrieved June 22, 2021 at https://medicalxpress.com/news/2021-06-treatment-sequence-esophageal-cancer. html
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