One-year survey of carcinoma of the oesophagus and stomach in Wales

Chemotherapy for advanced gastric cancer

BACKGROUND

Gastric cancer is the fifth most common cancer worldwide. In "Western" countries, most people are either diagnosed at an advanced stage, or develop a relapse after surgery with curative intent. In people with advanced disease, significant benefits from targeted therapies are currently limited to HER-2 positive disease treated with trastuzumab, in combination with chemotherapy, in first-line. In second-line, ramucirumab, alone or in combination with paclitaxel, demonstrated significant survival benefits. Thus, systemic chemotherapy remains the mainstay of treatment for advanced gastric cancer. Uncertainty remains regarding the choice of the regimen.

OBJECTIVES

To assess the efficacy of chemotherapy versus best supportive care (BSC), combination versus single-agent chemotherapy and different chemotherapy combinations in advanced gastric cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE and Embase up to June 2016, reference lists of studies, and contacted pharmaceutical companies and experts to identify randomised controlled trials (RCTs).

SELECTION CRITERIA

We considered only RCTs on systemic, intravenous or oral chemotherapy versus BSC, combination versus single-agent chemotherapy and different chemotherapy regimens in advanced gastric cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified studies and extracted data. A third investigator was consulted in case of disagreements. We contacted study authors to obtain missing information.

MAIN RESULTS

We included 64 RCTs, of which 60 RCTs (11,698 participants) provided data for the meta-analysis of overall survival. We found chemotherapy extends overall survival (OS) by approximately 6.7 months more than BSC (hazard ratio (HR) 0.3, 95% confidence intervals (CI) 0.24 to 0.55, 184 participants, three studies, moderate-quality evidence). Combination chemotherapy extends OS slightly (by an additional month) versus single-agent chemotherapy (HR 0.84, 95% CI 0.79 to 0.89, 4447 participants, 23 studies, moderate-quality evidence), which is partly counterbalanced by increased toxicity. The benefit of epirubicin in three-drug combinations, in which cisplatin is replaced by oxaliplatin and 5-FU is replaced by capecitabine is unknown.Irinotecan extends OS slightly (by an additional 1.6 months) versus non-irinotecan-containing regimens (HR 0.87, 95% CI 0.80 to 0.95, 2135 participants, 10 studies, high-quality evidence).Docetaxel extends OS slightly (just over one month) compared to non-docetaxel-containing regimens (HR 0.86, 95% CI 0.78 to 0.95, 2001 participants, eight studies, high-quality evidence). However, due to subgroup analyses, we are uncertain whether docetaxel-containing combinations (docetaxel added to a single-agent or two-drug combination) extends OS due to moderate-quality evidence (HR 0.80, 95% CI 0.71 to 0.91, 1466 participants, four studies, moderate-quality evidence). When another chemotherapy was replaced by docetaxel, there is probably little or no difference in OS (HR 1.05; 0.87 to 1.27, 479 participants, three studies, moderate-quality evidence). We found there is probably little or no difference in OS when comparing capecitabine versus 5-FU-containing regimens (HR 0.94, 95% CI 0.79 to 1.11, 732 participants, five studies, moderate-quality evidence) .Oxaliplatin may extend (by less than one month) OS versus cisplatin-containing regimens (HR 0.81, 95% CI 0.67 to 0.98, 1105 participants, five studies, low-quality evidence). We are uncertain whether taxane-platinum combinations with (versus without) fluoropyrimidines extend OS due to very low-quality evidence (HR 0.86, 95% CI 0.71 to 1.06, 482 participants, three studies, very low-quality evidence). S-1 regimens improve OS slightly (by less than an additional month) versus 5-FU-containing regimens (HR 0.91, 95% CI 0.83 to 1.00, 1793 participants, four studies, high-quality evidence), however since S-1 is used in different doses and schedules between Asian and non-Asian population, the applicability of this finding to individual populations is uncertain.

AUTHORS' CONCLUSIONS

Chemotherapy improves survival (by an additional 6.7 months) in comparison to BSC, and combination chemotherapy improves survival (by an additional month) compared to single-agent 5-FU. Testing all patients for HER-2 status may help to identify patients with HER-2-positive tumours, for whom, in the absence of contraindications, trastuzumab in combination with capecitabine or 5-FU in combination with cisplatin has been shown to be beneficial. For HER-2 negative people, all different two-and three-drug combinations including irinotecan, docetaxel, oxaliplatin or oral 5-FU prodrugs are valid treatment options for advanced gastric cancer, and consideration of the side effects of each regimen is essential in the treatment decision. Irinotecan-containing combinations and docetaxel-containing combinations (in which docetaxel was added to a single-agent or two-drug (platinum/5-FUcombination) show significant survival benefits in the comparisons studied above. Furthermore, docetaxel-containing three-drug regimens have increased response rates, but the advantages of the docetaxel-containing three-drug combinations (DCF, FLO-T) are counterbalanced by increased toxicity. Additionally, oxaliplatin-containing regimens demonstrated a benefit in OS as compared to the same regimen containing cisplatin, and there is a modest survival improvement of S-1 compared to 5-FU-containing regimens.Whether the survival benefit for three-drug combinations including cisplatin, 5-FU, and epirubicin as compared to the same regimen without epirubicin is still valid when second-line therapy is routinely administered and when cisplatin is replaced by oxaliplatin and 5-FU by capecitabine is questionable. Furthermore, the magnitude of the observed survival benefits for the three-drug regimens is not large enough to be clinically meaningful as defined recently by the American Society for Clinical Oncology (Ellis 2014). In contrast to the comparisons in which a survival benefit was observed by adding a third drug to a two-drug regimen at the cost of increased toxicity, the comparison of regimens in which another chemotherapy was replaced by irinotecan was associated with a survival benefit (of borderline statistical significance), but without increased toxicity. For this reason irinotecan/5-FU-containing combinations are an attractive option for first-line treatment. Although they need to be interpreted with caution, subgroup analyses of one study suggest that elderly people have a greater benefit form oxaliplatin, as compared to cisplatin-based regimens, and that people with locally advanced disease or younger than 65 years might benefit more from a three-drug regimen including 5-FU, docetaxel, and oxaliplatin as compared to a two-drug combination of 5-FU and oxaliplatin, a hypothesis that needs further confirmation. For people with good performance status, the benefit of second-line chemotherapy has been established in several RCTs.

Multidetector Computed Tomography Versus Staging Laparoscopy for the Detection of Peritoneal Metastases in Esophagogastric Junctional and Gastric Cancer

OBJECTIVE

Staging laparoscopy (SL) is the gold standard investigation for detecting peritoneal metastases (PM) in patients with esophagogastric cancer but computed tomography (CT) has undergone significant improvements in recent years. The aim of this study was to investigate whether CT can replace SL in the detection of PM.

MATERIALS AND METHODS

Patients undergoing SL between January 2008 and December 2009 were identified from a prospectively collected database, operation notes were reviewed for the detection of PM. Corresponding CTs were reassessed by 2 experienced gastrointestinal radiologists, blinded to the SL results.

RESULTS

In total, 74 patients undergoing SL were included. Sensitivity and specificity of SL for PM were 94.1% (95% confidence interval, 69.2-99.7) and 100% (90.7-100). Sensitivity and specificity of CT were 58.8% (33.5-80.6) and 89.6% (76.6-96.1), respectively. Area under the curve of receiver operating characteristic curves for SL and CT were 0.971 (SE, 0.033) and 0.742 (SE, 0.78), respectively.

CONCLUSIONS

CT cannot replace SL for the detection of PM in lower esophageal and gastric cancer.

Outcome after Transthoracic Resection of Carcinoma of the Oesophagus and Oesophago-Gastric Junction

Aims:

To assess the postoperative morbidity and mortality, length of stay and long-term survival after resection of carcinoma of the oesophagus and gastro-oesophageal junction, after establishment of a new surgical team unit between thoracic and gastroenterologic surgeons.

Methods:

We analysed the prospective collected data of 166 consecutive patients who underwent a transthoracic oesophageal resection between June 1997 and December 2003.

Results:

There were 119 men and 47 women. The median age was 63 years (range 36–81). Fifty-five patients (33 %) had squamous cell carcinoma and 111 (67 %) had adenocarcinoma. Postoperative complications occurred in a total of 60 patients (36 %). Ten patients (6 %) died postoperatively, eight (4.8 %) due to medical and two (1.2 %) due to surgical complications. The median postoperative length of stay was 11 days (range 6–75). The overall 3- and 5- years survival was 35.6 % and 30.6 % respectively. Survival was adversely affected by patient age and tumor stage.

Conclusions:

Concentrating resection for carcinoma of the oesophagus and oesophagogastric junction to a dedicated team of specialists, including both gastrointestinal and thoracic surgeons as well as thoracic-anaesthesiological know-how, results in acceptable complication rates as well as low mortality rates especially due to surgical complications.

Predictors of postoperative complications in elderly and oldest old patients with gastric cancer

BACKGROUND

The incidence of gastric cancer has been increasing among elderly persons in Japan. This study aimed to clarify risk factors for postoperative complications in oldest old patients with gastric cancer.

METHODS

One-hundred ninety patients more than 75 years old with gastric cancer underwent gastrectomy between 2000 and 2011. Patients were classified into two groups: group A included 29 patients who were 85 years or older (oldest old patients), and group B included 161 patients who were 75-84 years of age. Perioperative parameters associated with complications were compared in each group.

RESULTS

The preoperative estimated glomerular filtration rate was significantly lower in group A (p = 0.03). The two groups significantly differed in performance status (p = 0.018). Patients in group A received a lesser extent of lymph node dissection and had fewer lymph nodes excised. As a result, the duration of the operation was significantly shorter in group A. There were no significant differences in the frequency or grade of total complications or mortality between the two groups. Operative hemorrhage (>300 ml) and Hiroshima POSSUM (predicted morbidity risk >40) were risk factors in both groups A and B; the risk factors of preoperative serum albumin level and prognostic nutritional index (PNI) were specific to group A.

CONCLUSIONS

Adjustments to the extent of surgery among oldest old patients most likely reduces the incidence of postoperative complications in this group. Preoperative serum albumin level and PNI are significant predictors of postoperative complications in oldest old patients with gastric cancer.

Prediction of survival by tumor area on endosonography after definitive chemoradiotherapy for locally advanced squamous cell carcinoma of the esophagus

BACKGROUND

Definitive chemoradiotherapy (CRT) is a reasonable approach for patients with locally advanced esophageal cancer who are not surgical candidates. This study was performed to investigate whether endosonography (EUS) assessment of tumor area response is a useful prognostic marker in patients with squamous cell carcinoma (SCC) of the esophagus who receive definitive CRT.

METHODS

A total of 33 patients who received definitive CRT for locally advanced esophageal SCC were enrolled. The maximal transverse cross-sectional area of the tumor was measured before and after definitive therapy. EUS response was defined as a ≥50% reduction of the tumor area after definitive CRT.

RESULTS

Based on EUS evaluation, there were 20 nonresponders (60.6%) and 13 responders (39.4%). The median progression-free survival (PFS) was significantly longer in EUS responders than EUS nonresponders (p = 0.005). However, there was no statistical significance in overall survival according to EUS response (p = 0.120). During multivariate analysis, EUS response to definitive CRT was the only significant factor associated with PFS (p = 0.045), whereas EUS response to definitive CRT was not associated with overall survival (p = 0.221).

CONCLUSIONS

A reduction of the maximal cross-sectional tumor area measured by EUS correlates with a superior prognosis in patients with locally advanced SCC of the esophagus after definitive CRT.

Chemoradiotherapy, with adjuvant surgery for local control, confers a durable survival advantage in adenocarcinoma and squamous cell carcinoma of the oesophagus

INTRODUCTION

Oesophageal cancer usually presents with systemic disease, necessitating systemic therapy. Neo-adjuvant chemoradiotherapy improves short-term survival, but its long-term impact is disputed because of limited accrual, treatment-protocol heterogeneity and a short follow-up of randomised trials.

AIMS

Long-term results of two simultaneous randomised controlled trials (RCTs) comparing neo-adjuvant chemo-radiotherapy and surgery (MMT) with surgical monotherapy were examined, and the response of adenocarcinoma (AC) and squamous cell carcinoma (SCC) to identical regimens compared.

METHODS

Between 1990 and 1997, two RCTs were undertaken on 211 patients. Patients with AC (n=113) or SCC (n=98) were separately-randomised to identical protocols of MMT or surgical monotherapy.

RESULTS

211 patients were followed to 206 months; 104 patients were randomised to MMT (58 AC and 46 SCC, respectively) and 107 to surgery. MMT provided a significant survival-advantage over surgical monotherapy for AC (P=0.004), SCC (P=0.01). There was a 54% relative risk-reduction in lymph-node metastasis following MMT, compared with surgery (64% versus 29%, P<0.001). MMT produced a pathologic complete response (pCR) in 25% and 31% of AC and SCC, respectively. Survival advantage accrued to MMT, pCR and node-negative patients: AC pCR versus surgical monotherapy (P=0.001); residual disease following MMT versus surgical monotherapy (P=0.008); SCC pCR versus surgical monotherapy (P=0.033).

CONCLUSIONS

A survival advantage for MMT persisted long-term in AC and was replicated in SCC. MMT produced loco-regional tumour down-staging to extinction in 25-31% of patients, potentially permitting personalised treatment in this cohort that avoids the morbidity and mortality associated with resection. Node-negative patients with residual localised disease following MMT had a survival advantage over node-negative patients following surgery alone, supporting a systemic effect on micro-metastatic disease.

Multimodality therapy for cancers of the esophagus and gastric cardia

The role of multimodal treatment in the management of esophageal cancer is controversial. There are conflicting results from studies on the effect of neoadjuvant and/or adjuvant treatment on long-term survival. Following a search of the Medline database, the authors examine the results of randomized studies on the various treatment protocols available and discuss future therapeutic improvements.

Multidisciplinary Versus One-on-One Setting: A Qualitative Study of Clinicians' Perceptions of Their Relationship With Patients With Prostate Cancer

PURPOSE

Previous studies indicate that a multidisciplinary approach could be suitable for dealing with the complex issues faced by physicians in the management of prostate cancer; however, few studies have investigated clinicians' perceptions of multidisciplinary care. Our aim was to evaluate clinicians' perceptions of the patient-clinician relationship in a multidisciplinary context, and to compare this with physicians' perceptions of providing care independently.

METHODS

A qualitative observational study was performed in 2009. Three radiation oncologists, three urologists, three medical oncologists and one psychologist from the multidisciplinary clinic (MDC) team at the Prostate Program of Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy, were interviewed to assess their perceptions of their relationship with the patient.

RESULTS

Clinicians reported that the MDC has advantages regarding providing patients with more accurate information and acquiring information from patients, but a clear preference for a multidisciplinary setting did not emerge. Clinicians reported that in one-on-one examinations (1) they feel more comfortable listening to the patient and more able to manage communication, and that (2) the process of building trust is easier.

CONCLUSION

Clinicians appear to recognize the value of the MDC in terms of effective communication with patients but feel that other aspects of relationship building are hindered in a multidisciplinary setting. Organizational and teamwork issues need to be addressed to optimize the implementation of a multidisciplinary approach.

Targeting therapy for esophageal cancer in patients aged 70 and over

BACKGROUND

While cancer is a disease of the elderly, these patients are under-represented in randomized trials. Esophageal cancer-management in the elderly is challenging because of the morbidity and mortality associated with surgery.

OBJECTIVES

We examined a strategy of neo-adjuvant chemo-radiotherapy (naCRT), followed by surgery or surveillance, in selected patients with cancer aged 70 and older.

METHODS

A prospectively-accrued database identified 56 consecutive patients over a 90-month period, who were aged 70years and over, presented with esophageal carcinoma and were treated with neo-adjuvant CRT (naCRT)±surgery.

RESULTS

Of 129 eligible patients, 66 (51%) received palliative measures, while 63 (49%) had curative intervention, namely 7 had surgery and 56 had naCRT±surgery. Of these 56 patients, 33 (59%) had adenocarcinoma (AC) and 23 (41%) had squamous cell carcinoma (SCC). Twenty-five (45%) had a complete clinical response (cCR), of which 6 had immediate resection; 4 (67%) had a complete pathological response (pCR); 19 patients with a cCR declined or were unfit for surgery and underwent surveillance; of these, 3 had interval esophagectomy; 16 were not offered or declined resection. Eight (50%) have survived ≥3years. Mean overall survival was 28months for the entire cohort; 47months for cCRs; 61months for patients undergoing primary resection, 46months for cCRs who did not undergo resection and 29months for those undergoing interval resection for recurrent disease. In cCRs, surgery did not provide a survival advantage (p=0.861).

CONCLUSION

cCR yields an overall 3-year survival of 50% without operation. As 45% of patients have a cCR to naCRT, obligatory resection in high-risk cCR patients makes little sense. With the option for salvage esophagectomy in re-emergent disease, this selective strategy is an attractive alternative for elderly patients with cancer.

Oesophagectomy rates and post-resection outcomes in patients with cancer of the oesophagus and gastro-oesophageal junction: a population-based study using linked health administrative linked data

Background

Hospital performance is being benchmarked increasingly against surgical indicators such as 30-day mortality, length-of-stay, survival and post-surgery complication rates. The aim of this paper was to examine oesophagectomy rates and post-surgical outcomes in cancers of the oesophagus and gastro-oesophageal junction and to determine how the addition of gastro-oesophageal cancer to oesophageal cancer impacts on these outcomes.

Methods

Our study population consisted of patients with a primary invasive oesophageal or gastro-oesophageal cancer identified from the NSW Cancer Registry from July 2000-Dec 2007. Their records were linked to the hospital separation data for determination of resection rates and post-resection outcomes. We used multivariate logistic regression analyses to examine factors associated with oesophagectomy and post-resection outcomes. Cox-proportional hazard regression analysis was used to examine one-year cancer survival following oesophagectomy.

Results

We observed some changes in resection rates and surgical outcomes with the addition of gastro-oesophageal cancer patients to the oesophageal cancer cohort. 14.6% of oesophageal cancer patients and 26.4% of gastro-oesophageal cancer patients had an oesophagectomy; an overall oesophagectomy rate of 18.2% in the combined cohort. In the combined cohort, oesophagectomy was associated with younger age, being male and Australian-born, having non-metastatic disease or adenocarcinoma and being admitted in a co-located hospital. Rates of length-of-stay >28 days (20.9% vs 19.7%), 30-day mortality (3.8% vs 2.7%) and one-year survival post-surgery (24.5% vs 23.1%) were similar between oesophageal cancer alone and the combined cohort; whilst 30-day complication rates were 21.5% versus 17.0% respectively. Some factors statistically associated with post-resection complication in oesophageal cancer alone were not significant in the overall cohort. Poorer post-resection outcomes were associated with some patient (older age, birthplace) and hospital-related characteristics (fiscal sector, area health service).

Conclusion

Outcomes following oesophagectomy in oesophageal and gastro-oesophageal cancer patients in NSW are within world benchmarks. Our study demonstrates that the inclusion of gastro-oesophageal cancer did alter some outcomes compared to analysis based solely on oesophageal cancer. As such, care must be taken with analyses based on administrative health data to capture all populations eligible for treatment and to understand the contribution of these subpopulations to overall outcomes.

Surgical resection for locoregional esophageal cancer is underutilized in the United States

BACKGROUND

Although esophagectomy provides the highest probability of cure in patients with esophageal cancer, many candidates are never referred for surgery. We hypothesized that esophagectomy for esophageal cancer is underused, and we assessed the prevalence of resection in national, state, and local cancer data registries.

STUDY DESIGN

Clinical stage, surgical and nonsurgical treatments, age, and race of patients with cancer of the esophagus were identified from the Surveillance, Epidemiology and End Results (SEER) registry (1988 to 2004), the Healthcare Association of NY State registry (HANYS 2007), and a single referral center (2000 to 2007). SEER identified a total of 25,306 patients with esophageal cancer (average age 65.0 years, male-to-female ratio 3:1). HANYS identified 1,012 cases of esophageal cancer (average age 67 years, M:F ratio 3:1); stage was not available from NY State registry data. A single referral center identified 385 patients (48 per year; average age 67 years, M:F 3:1). For SEER data, logistic regression was used to examine determinants of esophageal resection; variables tested included age, race, and gender.

RESULTS

Surgical exploration was performed in 29% of the total and only 44.2% of potentially resectable patients. Esophageal resection was performed in 44% of estimated cancer patients in NY State. By comparison, 64% of patients at a specialized referral center underwent surgical exploration, 96% of whom had resection. SEER resection rates for esophageal cancer did not change between 1988 and 2004. Males were more likely to receive operative treatment. Nonwhites were less likely to undergo surgery than whites (odds ratio 0.45, p < 0.001).

CONCLUSIONS

Surgical therapy for locoregional esophageal cancer is likely underused. Racial variations in esophagectomy are significant. Referral to specialized centers may result in an increase in patients considered for surgical therapy.

Combined pretherapeutic endoscopic and laparoscopic ultrasonography may predict survival of patients with upper gastrointestinal tract cancer

BACKGROUND

The combination of endoscopic and laparoscopic ultrasonography (EUS-LUS) is accurate for resectability assessment of patients with upper gastrointestinal cancer (UGIC). But neither the ability of EUS/LUS to predict long-term prognosis nor the potential impact on patient survival using this selection strategy has been investigated. This prospective, single-center study evaluated whether pretherapeutic EUS-LUS stratification related to the prognosis in UGIC patients and whether patient selection by this strategy provided a prognostic outcome comparable with survival data from the literature.

METHODS

Each patient had a pretherapeutic tumor node metastasis (TNM) stage and a resectability assessment assigned based on EUS-LUS findings. Survival curves were constructed and compared for each of the EUS-LUS TNM stage and resectability groups at the end of the observation period. Finally, the R0 resection rate, median, and 5-year survival rates were compared with the literature.

RESULTS

This study enrolled 936 consecutive patients with esophageal (n = 256), gastric (n = 273), or pancreatic (n = 407) cancer. A statistically significant survival difference (p < 0.01) between the different TNM stages and resectability groups predicted by EUS-LUS was observed regardless of the cancer type. The poor prognosis for the patients with irresectable or disseminated UGIC was accurately predicted by EUS and LUS. The R0 resection rate as well as the median and 5-year survival rates were comparable with data from the literature.

CONCLUSION

The pretherapeutic EUS-LUS patient stratification related significantly to the final prognosis for UGIC patients. An EUS-LUS-based patient selection strategy seemed to provide a prognostic outcome similar to data from computed tomography (CT)-based populations.

Surgical outcomes associated with oesophagectomy in New South Wales: an investigation of hospital volume

INTRODUCTION

Resection remains the standard treatment for curable oesophageal cancer. By linking the NSW Central Cancer Registry (CCR) and the NSW Admitted Patient Data Collection (APDC) databases, mortality, post-resection complication and survival associated with oesophagectomy were investigated.

METHODS

All patients diagnosed with oesophageal cancer from 2000 to 2005 as recorded in the CCR (n = 2,082) were linked with records in the APDC, giving a total of 17,205 episodes of care. Over 15% (n = 321) of all patients underwent an oesophagectomy.

RESULTS AND DISCUSSION

The overall 30-day mortality rate following resection was 3.7%, ranging from 2.6% in high volume hospitals to 6.4% in low volume hospitals. Three-year absolute survival for localised-regional disease following oesophagectomy was 64% (95%CI 54-73%) in high-volume hospitals, 58% (95%CI 46-68%) in mid-volume and 45% (95%CI 23-65%) in low-volume hospitals. The post-resection complication rate was 19% (95%CI 13-26%) for high-volume hospital, 24% (95%CI 13-40%) in low-volume and 31% (95%CI 22-41%) in mid-volume hospitals.

CONCLUSION

Oesophagectomy in NSW is performed with satisfactory results. However, there is a suggestion that higher- rather than lower-volume hospitals have better post-resection outcomes.

Chemotherapy for advanced gastric cancer

BACKGROUND

Gastric cancer currently ranks second in global cancer mortality. Most patients are either diagnosed at an advanced stage, or develop a relapse after surgery with curative intent. Apart from supportive care and palliative radiation to localized (e.g. bone) metastasis, systemic chemotherapy is the only treatment option available in this situation.

OBJECTIVES

To assess the efficacy of chemotherapy versus best supportive care, combination versus single agent chemotherapy and different combination chemotherapy regimens in advanced gastric cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE up to March 2009, reference lists of studies, and contacted pharmaceutical companies and national and international experts.

SELECTION CRITERIA

Randomised controlled trials on systemic intravenous chemotherapy versus best supportive care, combination versus single agent chemotherapy and different combination chemotherapies in advanced gastric cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. A third investigator was consulted in case of disagreements. We contacted study authors to obtain missing information.

MAIN RESULTS

Thirty five trials, with a total of 5726 patients, have been included in the meta-analysis of overall survival. The comparison of chemotherapy versus best supportive care consistently demonstrated a significant benefit in overall survival in favour of the group receiving chemotherapy (hazard ratios (HR) 0.37; 95% confidence intervals (CI) 0.24 to 0.55, 184 participants). The comparison of combination versus single-agent chemotherapy provides evidence for a survival benefit in favour of combination chemotherapy (HR 0.82; 95% CI 0.74 to 0.90, 1914 participants). The price of this benefit is increased toxicity as a result of combination chemotherapy. When comparing 5-FU/cisplatin-containing combination therapy regimens with versus without anthracyclines (HR 0.77; 95% CI 0.62 to 0.95, 501 participants) and 5-FU/anthracycline-containing combinations with versus without cisplatin (HR 0.82; 95% CI 0.73 to 0.92, 1147 participants) there was a significant survival benefit for regimens including 5-FU, anthracyclines and cisplatin. Both the comparison of irinotecan versus non-irinotecan (HR 0.86; 95% CI 0.73 to 1.02, 639 participants) and docetaxel versus non-docetaxel containing regimens (HR 0.93; 95% CI 0.75 to 1.15, 805 participants) show non-significant overall survival benefits in favour of the irinotecan and docetaxel-containing regimens.

AUTHORS' CONCLUSIONS

Chemotherapy significantly improves survival in comparison to best supportive care. In addition, combination chemotherapy improves survival compared to single-agent 5-FU. All patients should be tested for their HER-2 status and trastuzumab should be added to a standard fluoropyrimidine/cisplatin regimen in patients with HER-2 positive tumours. Two and three-drug regimens including 5-FU, cisplatin, with or without an anthracycline, as well as irinotecan or docetaxel-containing regimens are reasonable treatment options for HER-2 negative patients.

Operative mortality after gastric cancer resection and long-term survival differences across Europe

BACKGROUND

: Little is known at a population level about operative mortality after surgery for gastric cancer and whether differences between countries can explain differences in long-term survival. This study compared operative mortality recorded by ten cancer registries in seven European countries.

METHODS

: Non-conditional logistic regression analysis was performed to estimate the independent effect of the studied factors on mortality within 30 days of surgery. A multivariable survival model was employed with and without operative mortality.

RESULTS

: The overall operative mortality rate in 1611 patients studied was 8.9 (range 5.2-16) per cent. Country of residence was a significant prognostic factor in the multivariable analysis. The likelihood of operative mortality was lower in Italy, France and the UK than in the Netherlands, Spain, Slovenia and Poland. Age, type of gastrectomy and stage at diagnosis were also significant factors. Cancer site was not found to be significant in the multivariable analysis. The overall 5-year relative survival rate varied between 42.0 per cent (Italy) and 24 per cent (Poland); after excluding operative mortality, the 5-year survival rate was 44.3 and 28 per cent respectively.

CONCLUSION

: Within Europe, the substantial differences in operative mortality after gastrectomy only partly explain marked differences in survival after gastric cancer resection.

A pre-operative elevated neutrophil: lymphocyte ratio does not predict survival from oesophageal cancer resection

Background

Elevated pre-operative neutrophil: lymphocyte ratio (NLR) has been identified as a predictor of survival in patients with hepatocellular and colorectal cancer. The aim of this study was to examine the prognostic value of an elevated preoperative NLR following resection for oesophageal cancer.

Methods

Patients who underwent resection for oesophageal carcinoma from June 1997 to September 2007 were identified from a local cancer database. Data on demographics, conventional prognostic markers, laboratory analyses including blood count results, and histopathology were collected and analysed.

Results

A total of 294 patients were identified with a median age at diagnosis of 65.2 (IQR 59-72) years. The median pre-operative time of blood sample collection was three days (IQR 1-8). The median neutrophil count was 64.2 × 10^-9/litre, median lymphocyte count 23.9 × 10^-9/litre, whilst the NLR was 2.69 (IQR 1.95-4.02). NLR did not prove to be a significant predictor of number of involved lymph nodes (Cox regression, p = 0.754), disease recurrence (p = 0.288) or death (Cox regression, p = 0.374). Furthermore, survival time was not significantly different between patients with high (≥ 3.5) or low (< 3.5) NLR (p = 0.49).

Conclusion

Preoperative NLR does not appear to offer useful predictive ability for outcome, disease-free and overall survival following oesophageal cancer resection.

Gastric cancer surgery--a balance of risk and radicality

INTRODUCTION

The aim of this study was to determine whether tailoring the extent of resection would allow radical gastric cancer surgery to be performed safely in a UK population.

PATIENTS AND METHODS

A total of 180 consecutive patients (median age 70 years; male:female ratio 2:1) undergoing resection for gastric adenocarcinoma with curative intent were studied. Extent of lymphadenectomy was based upon pre-operative and intra-operative staging, and balanced against the patient's age and fitness.

RESULTS

In the study group, 83 patients underwent subtotal or distal partial gastrectomy and 97 patients underwent total or proximal partial gastrectomy. Operative procedures were: D1 lymphadenectomy (n = 62); modified (spleen and pancreas pre-serving) D2 lymphadenectomy (n = 73); D2 lymphadenectomy (n = 42); and extended resection (n = 3). TNM classification was: stage 1 (n = 45); stage 2 (n = 37); stage 3 (n = 61); and stage 4 (n = 37). Of the patients, 48 developed postoperative complications including 17 patients with a major surgical complication. The in-hospital mortality was 1.7% (3 of 180). Predicted mortality according to POSSUM and P-POSSUM was 21.4% and 7.8%, respectively. Disease-specific 5-year survival according to stage was 85.4%, 64.2%, 33.3%, and 6.9%.

CONCLUSIONS

By tailoring the extent of resection and balancing risk and radicality, gastric cancer surgery can be performed with low mortality in Western patients.

Oxford experience with neoadjuvant chemotherapy and surgical resection for esophageal adenocarcinomas and squamous cell tumors

The Medical Research Council trial for oesophageal cancer (OEO2) trial demonstrated a clear survival benefit from neoadjuvant chemotherapy in resectable esophageal carcinoma. Since February 2000 it has been our practice to offer this chemotherapy regime to patients with T2 and T3 or T1N1 tumors. We analyzed prospectively collected data of patients who received neoadjuvant chemotherapy prior to esophageal resection under the care of a single surgeon. Complications of treatment and overall outcomes were evaluated. A total of 194 patients had cisplatin and 5-fluorouracil prior to esophageal resection. Six patients (5.7%) had progressive disease and were inoperable (discovered in four at surgery). During chemotherapy one patient died and one perforated (operated immediately). Complications including severe neutropenia, coronary artery spasm, renal impairment and pulmonary edema led to the premature cessation of chemotherapy in 12 patients (6.2%). A total of 182 patients with a median age of 63 (range 30-80), 41 squamous and 141 adenocarcinomas underwent surgery. Operations were 91 left thoracoabdominal (50%), 45 radical transhiatal (25%), 40 Ivor-Lewis (22%) and six stage three (3%), and 78.6% had microscopically complete (R0) resections. Median survival was 28 months with 77.3% surviving for 1 year and 57.7% for 2 year. In hospital mortality was 5.5% and anastomotic leak rate 7.7%. A radical surgical approach to the primary tumor in combination with OEO2 neoadjuvant chemotherapy has led to a high R0 resection rate and good survival with acceptable morbidity and mortality.

A phase II study of leucovorin, 5-FU and docetaxel combination chemotherapy in patients with inoperable or postoperative relapsed gastric cancer

PURPOSE

To estimate the effect and toxicity of bimonthly low-dose leucovorin (LV) and fluorouracil (5-FU) bolus plus continuous infusion(LV5FU2) with docetaxel combination chemotherapy in patients with inoperable or postoperative relapsed gastric cancer.

MATERIALS AND METHODS

Total 27 patients are enrolled in this study. LV 20 mg/m(2) (bolus), 5FU 400 mg/m(2) (bolus), 5-FU 600 mg/m(2) (24-hour continuous infusion) on day 1, 2, 15, and 16, docetaxel 60 mg/m(2) (1-hour infusion) on day 15 every 4 weeks.

RESULTS

Total of 141 cycles were administered and response rate were 36.8% with 2 complete response (10.5%) and 5 partial response (26.3%) in 19 evaluable patients. The median response duration is 8.1 months (95% CI, 4.0 approximately 12.1). The median progression-free survival time is 6.7 months (95% CI, 5.0 approximately 8.5) and the median overall survival time is 11.9 months (95% CI, 4.8 approximately 19.1). The grade 3-4 toxicity of neutropenia (24.8%) and anemia (11.3%), neutropenic fever (2.8%) is observed. The grade 1 toxicity of injection site reaction is observed all patients and the grade 1-2 toxicity of alopecia is observed 60%.

CONCLUSIONS

LV5FU2 with docetaxel combination chemotherapy is effective and tolerable in patients with inoperable or postoperative relapsed gastric cancer.

Prognostic significance of gastrin expression in patients undergoing R0 gastrectomy for adenocarcinoma

BACKGROUND

Gastrointestinal (GI) hormones regulate several GI functions, including the proliferation and repair of normal mucosa, and hormone receptors may therefore be implicated in the growth, invasion, and metastasis of cancers of the GI tract. The aim of this study was to determine the cellular distribution of gastrin in intestinal-type gastric cancers, and to determine its relationship to outcomes after R0 gastrectomy.

METHODS

Eighty-six consecutive patients undergoing R0 gastrectomy for adenocarcinoma were studied. Normal gastric mucosa and tumor were stained for gastrin and their specific cellular distribution was determined.

RESULTS

The duration of survival of patients whose tumors exhibited well-differentiated gastrin-positive tumor (GPT) cells (n = 12) was significantly poorer than that of patients whose tumors were GPT-negative (5-year survival, 30% vs 54%; P = 0.037). Patients with GPT-positive intestinal-type gastric cancer (5 of 47 patients) had the poorest survival of all (median, 14 months; 5-year survival, 0%; P = 0.006). In a multivariate analysis, only lymph node metastases (hazard ratio [HR], 2.13; 95% confidence interval [CI], 1.2 to 3.79; P = 0.01) and the presence of GPT cells (HR, 6.61; 95% CI, 1.74 to 25.09; P = 0.01) were independently and significantly associated with durations of survival in patients with intestinal-type gastric cancer.

CONCLUSION

The presence of GPT cells in patients with gastric adenocarcinoma is a significant and independent prognostic indicator.

Influence of socio-economic deprivation on outcomes for patients diagnosed with oesophageal cancer

OBJECTIVE

To determine the influence of deprivation on outcomes for patients with oesophageal cancer.

MATERIAL AND METHODS

A total of 1196 consecutive patients with oesophageal carcinoma presenting to a regional multidisciplinary team between 1 January 1998 and 31 August 2005 were studied prospectively and deprivation scores calculated using the Indices of Multiple Deprivation (IMD) of the National Assembly for Wales. The patients were subdivided into quintiles for analysis.

RESULTS

Inhabitants of the most deprived areas (quintile 5) were younger at presentation (median age 67 years versus 70 years, p = 0.01) and were more likely to have squamous cell carcinomas (SCCs) (p = 0.002) in comparison with patients from the least deprived areas (quintile 1). Stage of disease and morbidity did not correlate with deprivation quintile, but operative mortality was greater in quintile 1 versus 5 (1.9% versus 5.8%, p = 0.281). Overall 5-year survival for those patients undergoing oesophagectomy was unrelated to deprivation quintile (1 versus 5, 24% versus 33%, p = 0.8246), but was lower following definitive chemoradiotherapy (dCRT) for the least deprived quintiles (1, 2 & 3 versus 4 & 5, 35% versus 16%, p = 0.0272).

CONCLUSIONS

Although deprivation was associated with younger age, SCC and a trend towards higher operative mortality, survival after diagnosis and oesophagectomy were unrelated to deprivation.

Hospital volume does not influence long-term survival of patients undergoing surgery for oesophageal or gastric cancer

BACKGROUND

Guidelines suggest that surgery for oesophageal and gastric cancer should be conducted in large cancer centres. This national study examined the relationship between hospital volume and outcome in Scotland.

METHODS

This was a prospective, population-based study of 3293 consecutive patients with oesophageal or gastric cancer diagnosed between 1997 and 1999. Some 1302 patients underwent surgery and were followed for 5 years after operation.

RESULTS

The 5-year adjusted overall survival rate for the 3293 patients was 18.7 (95 per cent confidence interval (c.i.) 17.2 to 20.2) per cent and that after surgical resection was 39.6 (95 per cent c.i. 36.3 to 43.0) per cent. Death within 1 year after surgical resection was associated with a postoperative complication (odds ratio (OR) 2.5 (95 per cent c.i. 1.6 to 3.8); P < 0.001) or resection margin involvement by tumour (OR 7.2 (95 per cent c.i. 1.1 to 47.5); P = 0.042) after adjustment for age, sex and tumour location. There was no relationship between hospital volume and postoperative morbidity or mortality, nor between survival and volume of patients either for hospital of diagnosis or hospital of surgery.

CONCLUSION

This population-based study of oesophageal and gastric cancer suggests that the link between hospital volume and long-term survival for patients undergoing surgery requires re-evaluation.

Multidisciplinary teams in cancer care: are they effective in the UK?

Cancer care can be complex, and given the wide range and numbers of health-care professionals involved, an enormous potential for poor coordination and miscommunication exists. Multidisciplinary teams (MDTs) should improve coordination, communication, and decision making between health-care team members and patients, and hopefully produce more positive outcomes. This review describes the many practical barriers to the successful implementation of MDT working, and shows that despite an increase in the delivery of cancer services via this method, research showing the effectiveness of MDT working is scarce.

A prospective comparison of multidisciplinary treatment of oesophageal cancer with curative intent in a UK cancer network

AIMS

Combined modality therapy (with chemotherapy+/-radiotherapy) has become a standard treatment for locally advanced oesophageal cancer. However, there appears to be no compelling evidence for one treatment type or combination to suit all and at this time the clinical multi-disciplinary team (MDT) forms an important role in selecting optimal therapies for the individual. This prospective comparison in one cancer network, looks at the outcomes of this decision making process.

METHODS

Over a five year period 1998-2003, data were prospectively collected on all 330 consecutive patients, referred to a tertiary specialised MDT for whom curative treatment was the planned intent. Patients were managed according to an agreed local protocol and allocated to receive one of 5 treatments: surgery alone (S), pre-operative chemotherapy (C+S), pre-operative chemo-radiotherapy (CRT+S), definitive chemo-radiotherapy (CRT) and radiotherapy alone (RT).

RESULTS

The 2 and 5 year survival for all patients receiving potentially curative treatment were 49% and 26% respectively. With 2 and 5 year survival for S, CRT+S, C+S, CRT and RT being 53,21; 57,40; 37,27; 50,27; 23,0 months respectively. Of the surgical therapies, mortality was highest in the CRT+S group, versus C+S and S; 12.5%, 1.6%, 4.5% respectively (p=0.025). Non-surgical based therapies had more than double the incidence of local relapses compared to surgical based therapies; however the CRT group had an overall survival comparable with S alone. The commonest sites of distant relapse were liver (56%), lung (38%), bone (32%) and non-regional lymph nodes (24%).

CONCLUSION

The results suggest that in patients who are deemed unfit for surgical intervention, definitive chemoradiotherapy remains a viable alternative; they also lend further support to selected case triple modality therapy. These areas should be further examined in the context of randomised controlled phase III trials.

Chemotherapy in advanced gastric cancer: a systematic review and meta-analysis based on aggregate data

PURPOSE

This systematic review and meta-analysis were performed to assess the efficacy and tolerability of chemotherapy in patients with advanced gastric cancer.

METHODS

Randomized phase II and III clinical trials on first-line chemotherapy in advanced gastric cancer were identified by electronic searches of Medline, Embase, the Cochrane Controlled Trials Register, and Cancerlit; hand searches of relevant abstract books and reference lists; and contact to experts. Meta-analysis was performed using the fixed-effect model. Overall survival, reported as hazard ratio (HR) with 95% CI, was the primary outcome measure.

RESULTS

Analysis of chemotherapy versus best supportive care (HR = 0.39; 95% CI, 0.28 to 0.52) and combination versus single agent, mainly fluorouracil (FU) -based chemotherapy (HR = 0.83; 95% CI = 0.74 to 0.93) showed significant overall survival benefits in favor of chemotherapy and combination chemotherapy, respectively. In addition, comparisons of FU/cisplatin-containing regimens with versus without anthracyclines (HR = 0.77; 95% CI, 0.62 to 0.95) and FU/anthracycline-containing combinations with versus without cisplatin (HR = 0.83; 95% CI, 0.76 to 0.91) both demonstrated a significant survival benefit for the three-drug combination. Comparing irinotecan-containing versus nonirinotecan-containing combinations (mainly FU/cisplatin) resulted in a nonsignificant survival benefit in favor of the irinotecan-containing regimens (HR = 0.88; 95% CI, 0.73 to 1.06), but they have never been compared against a three-drug combination.

CONCLUSION

Best survival results are achieved with three-drug regimens containing FU, an anthracycline, and cisplatin. Among these, regimens including FU as bolus exhibit a higher rate of toxic deaths than regimens using a continuous infusion of FU, such as epirubicin, cisplatin, and continuous-infusion FU.

Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer

We aim to compare the outcomes of patients undergoing R0 esophagectomy by a multidisciplinary team (MDT) with outcomes after surgery alone performed by surgeons working independently in a UK cancer unit. An historical control group of 77 consecutive patients diagnosed with esophageal cancer and undergoing surgery with curative intent by six general surgeons between 1991 and 1997 (54 R0 esophagectomies) were compared with a group of 67 consecutive patients managed by the MDT between 1998 and 2003 (53 R0 esophagectomies, 26 patients received multimodal therapy). The proportion of patients undergoing open and closed laparotomy and thoracotomy decreased from 21% and 5%, respectively, in control patients, to 13% and 0% in MDT patients (chi2 = 11.90, DF = 1, P = 0.001; chi2 = 5.45, DF = 1, P = 0.02 respectively). MDT patients had lower operative mortality (5.7%vs. 26%; chi2 = 8.22, DF = 1, P = 0.004) than control patients, and were more likely to survive 5 years (52%vs. 10%, chi2 = 15.05, P = 0.0001). In a multivariate analysis, MDT management (HR = 0.337, 95% CI = 0.201-0.564, P < 0.001), lymph node metastases (HR = 1.728, 95% CI = 1.070-2.792, P = 0.025), and American Society of Anesthesiologists grade (HR = 2.207, 95% CI = 1.412-3.450, P = 0.001) were independently associated with duration of survival. Multidisciplinary team management and surgical subspecialization improved outcomes after surgery significantly for patients diagnosed with esophageal cancer.

A five-year audit of anal cancer in Wales

OBJECTIVES

A retrospective audit has been undertaken of Squamous (epidermoid) type of anal cancer diagnosed and treated in the principality of Wales over a five-year period (1995-99) with follow-up until 2005. The referral pattern, distribution, presenting symptoms, predisposing conditions, clinical findings and staging modalities were documented. The surgical and oncological treatment together with their outcome was analysed.

METHODS

Patients were identified from the Welsh Cancer Registry and the pathology databases of the 17 acute hospitals in Wales. Data was collected from the clinical and oncology case notes onto a purpose designed Microsoft access database.

RESULTS

There was a wide variation in data quality from the individual units. Twenty-six anal cancers were diagnosed per year in the region. Median age was 69 years. Ten percent had documented perianal Human Papilloma Virus related disease. Radiology was inconsistently used for staging. Eighty percent were referred for an oncology opinion; 50% had chemo-radiotherapy with a curative intent. The over-all Stoma rate was 35% and of these 18% had an abdomino perineal resection. The overall five-year survival was 45%.

CONCLUSIONS

This is a unique regional audit of anal cancer. Improvements need to be made in documentation particularly of staging, treatment, pathology reporting and outcome. This study concurs that Human Papilloma Virus appears to predispose to Squamous anal cancer. Radiological staging needs to be standardized according to best clinical practice. As recommended by NICE all patients should be referred to a multidisciplinary anal cancer team, which can provide individual treatment plans. Increased specialization could mean specialist regional MDTs for anal cancer.

Pilot Study of Preoperative Combined Modality Treatment for Locally Advanced Operable Oesophageal Carcinoma: Toxicities and Long-term Outcome

AIMS

Paclitaxel, a radiosensitiser, has significant activity in oesophageal cancer. We aimed to conduct a feasibility study of preoperative chemoradiation using paclitaxel, cisplatin and 5-fluorouracil (5-FU).

MATERIALS AND METHODS

Sixteen eligible patients were enrolled. Infusional 5-FU, paclitaxel and cisplatin were given for 6 weeks before and concurrent with radiation. Conformal radiotherapy was delivered in two phases (45 Gy in 25 fractions).

RESULTS

A total of 62.5% of the patients experienced Grade 3-4 toxicities, 50% required admission; one patient died during the neo-adjuvant phase. Twelve (75%) patients had oesophagectomy, and two (12.5%) died after surgery. Pathological complete remission (PCR) and minimal residual disease were observed in 25% (95% CI 0.5-49.5%) and 18% (95% CI 0-38%) of patients, respectively, who underwent surgery. The median survival was 39.7 months (95% CI 15, not reached); 1-, 2-, 3-, and 4-year survivals were 75% (95% CI 56.5-99.5), 56.3% (36.5-86.7), 50% (30.6-81.6), and 50% (30.6-81.6), respectively.

CONCLUSION

Paclitaxel, cisplatin and 5-FU (TCF)-chemoradiation is an active regimen; the current dose schedule tested is associated with unacceptable toxicity, and cannot be recommended for routine clinical use.

Chemotherapy for advanced gastric cancer

BACKGROUND

Gastric cancer currently ranks second in global cancer mortality. Most patients are either diagnosed at an advanced stage, or develop a relapse after apparently curative operation. Apart from supportive measures, systemic chemotherapy is the only treatment option available in this situation.

OBJECTIVES

To assess the effect of chemotherapy versus best supportive care, combination versus single agent chemotherapy and different combination chemotherapy regimens in advanced gastric cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE and EMBASE up to February 2004 and reference lists of articles. We also contacted pharmaceutical companies as well as national and international experts.

SELECTION CRITERIA

Randomised controlled trials on systemic intravenous chemotherapy versus best supportive care, combination versus single agent chemotherapy and different combination chemotherapies in advanced gastric cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. A third investigator was consulted in case of disagreements. We contacted study authors to obtain missing information.

MAIN RESULTS

Chemotherapy versus best supportive care consistently demonstrated a significant benefit in terms of overall survival in favour of the group receiving chemotherapy (Hazard Ratios (HR) 0.39; 95% confidence intervals (CI) 0.28 to 0.52). Combination versus single-agent chemotherapy provides evidence for a survival benefit in favour of combination chemotherapy (HR 0.85; 95% CI 0.76 to 0.96). Numbers included in these comparisons were 184 and 1338 participants respectively. This benefit is achieved at the price of increased toxicity in the combination chemotherapy arms. When comparing 5-FU/cisplatin-containing combination therapy regimens with anthracyclines versus those without anthracyclines (HR 0.77; 95% CI 0.62 to 0.95 based on 501 participants) and 5-FU/anthracycline-containing combinations with cisplatin versus those without cisplatin (HR 0.83; 95% CI 0.76 to 0.91 based on 1147 participants), there was a significant survival benefit for regimens including 5-FU, anthracyclines and cisplatin.

AUTHORS' CONCLUSIONS

Chemotherapy significantly improves survival in comparison to best supportive care. In addition, combination chemotherapy improves survival compared to single-agent 5-FU, but the effect size is much smaller. Among the combination chemotherapy regimens studied, best survival results are achieved with regimens containing 5-FU, anthracyclines and cisplatin. In this category, ECF (epirubicin, cisplatin and continuous infusion 5-FU) is tolerated best.

Dysphagia referrals to a district general hospital gastroenterology unit: hard to swallow

The aim of our study was to audit dysphagia referrals received by a specialist gastroenterology unit during an entire year. We used a prospective audit carried out over a 12-month period at the District General Hospital gastroenterology unit. The audit included 396 consecutive patients who were referred with swallowing difficulties. We found that 60 referrals (15.2%) were inaccurate and the patients had no swallowing problem. Of the 336 patients with genuine dysphagia, only 29 (8.6%) were new cancer cases. The large majority of subjects had benign disease mostly related to acid reflux. Weight loss was significantly associated with malignancy but also occurred in one third of patients with reflux alone. The temporal pattern of dysphagia was not significantly predictive of cancer. All the cancer patients were above the age of 50 years. Although patients were in general assessed rapidly after hospital referral, the productivity, in terms of early tumor diagnosis, was extremely low. We conclude that there is a substantial rate of inaccurate referrals of dysphagia patients. Most true cases of swallowing difficulty relate to benign disease. Even the devotion of considerable resources to the early diagnosis of esophago gastric malignancy in an attempt to conform with best practice guidelines results in a very low success rate in terms of the detection of potentially curable tumors.

Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer

OBJECTIVE

This study aimed at: (1) documenting the evolution of surgical results of esophagectomy in a high-volume center, (2) identifying predictive factors of pulmonary complications and mortality, and (3) examining whether preoperative chemoradiation therapy would complicate postoperative recovery.

SUMMARY BACKGROUND DATA

Pulmonary complications and mortality rate after esophagectomy remain substantial, and factors responsible have not been adequately studied. Neoadjuvant chemoradiation is widely used; it is hypothesized that this may lead to adverse postoperative outcome.

METHODS

Prospectively collected data were used to analyze outcome in 421 patients with intrathoracic squamous cell esophageal cancer who underwent resection. Logistic regression analyses determined independent predictors of pulmonary complications and death. Two time periods were compared: period I (January 1990 to June 1995) and period II (July 1995 to December 2001). In the later period, neoadjuvant chemoradiation therapy was introduced.

RESULTS

Transthoracic resections were carried out in 83% of patients. Neoadjuvant chemoradiation was given to 42% of patients in period II. Major pulmonary complications occurred in 15.9%, and were primarily responsible for 55% of hospital deaths. Thirty-day and hospital mortality rates were 1.4% and 4.8%, respectively. Logistic regression analysis identified age, operation duration, and proximal tumor location as risk factors for pulmonary complications, whereas advanced age and higher blood loss were predictive of mortality. Chemoradiation did not lead to worse outcome. When period I and II were compared, hospital mortality rate reduced from 7.8% to 1.1%, P = 0.001, with correspondingly less blood loss (median blood loss was 700 ml (range: 200-2700 (period I) and 450 ml (range: 100-7000) (period II), P < 0.01).

CONCLUSION

A 1.1% mortality rate was achieved in the last 6 years of the study period. Preoperative chemoradiation did not result in worse outcome. Reduction in mortality rate correlated with decreased blood loss.

Comparison of special interest computed tomography, endosonography and histopathological stage of oesophageal cancer

AIMS

To assess the strength of agreement between the perceived pre-operative stage of oesophageal tumours as determined by spiral computed tomography (CT) and endoscopic ultrasound (EUS), both alone and in combination, with the histopathological stage.

METHODS

Sixty patients with oesophageal cancer underwent both pre-operative CT and EUS performed by two consultant radiologists with a special interest in upper gastrointestinal radiology. The strength of the agreement between the radiological stage and the histopathological stage was determined by means of the weighted Kappa statistic (Kw).

RESULTS

Sensitivity for T and N stages was 58% and 79% for CT, and 72% and 91% for EUS. Specificity for T and N stages was 80% and 84% for CT, and 85% and 68% for EUS. Kw for T and N stages was 0.455 (p=0.0001) and 0.603 (p=0.0001) for CT compared with 0.604 (p=0.0001) and 0.610 (p=0.0001) for EUS. In patients when CT and EUS agreed regarding the T and N stages, the strength of agreement between the radiological and the histopathological stage was greater (Kw T 0.613 (p=0.0001), Kw N 0.781 (p=0.0001)).

CONCLUSION

CT and EUS are complimentary techniques for the staging of oesophageal tumours, and these results reinforce the importance of specialist radiology in stage directed management.

The role of staging investigations for oesophago-gastric carcinoma

AIMS

To study the frequency with which unresectable disease was identified on pre-operative staging investigations in patients with oesophago-gastric carcinoma, and to audit whether a staging protocol had reduced the rate of exploratory surgery.

METHODS

Ninety-eight patients with oesophageal carcinoma, 89 patients with adenocarcinoma of the gastro-oesophageal junction (GOJ) and 68 patients with gastric carcinoma were staged according to a protocol of computerised tomography, laparoscopy and endoscopic ultrasound.

RESULTS

The frequency with which each investigation identified unresectable disease was as follows: (a) computerised tomography-oesophagus 12/67, GOJ 13/58, stomach 10/60; (b) laparoscopy-oesophagus 3/22, GOJ 5/45, stomach 8/23; and (c) endoscopic ultrasound-oesophagus 15/55, GOJ 3/30. By tumour location, rates of exploratory surgery were 1/18 for the oesophagus, 12/35 for the GOJ and 4/42 for the stomach. All of the staging failures in patients with GOJ carcinomas related to posterior tumour extension into the lesser sac.

CONCLUSIONS

Staging investigations precluded resection in one-third of patients, the greatest yield being for laparoscopy in gastric carcinoma. In spite of this, 18% of patients undergoing surgical intervention underwent exploratory surgery alone, notably patients with GOJ carcinoma.

Endoscopic palliative treatment for esophageal and gastric cancer: techniques, complications, and survival in a population-based cohort of 948 patients

BACKGROUND

Under the auspices of the Scottish Audit of Gastric and Esophageal Cancer, we investigated treatment techniques, complications, and survival in a population-based cohort of patients undergoing endoscopic palliative therapy for esophageal or gastric cancer.

METHODS

A total of 948 patients undergoing endoscopic palliative therapy were identified prospectively and followed for a minimum of 1 year.

RESULTS

Expandable metal stent placement (506 patients) and LASER (117 patients) were the most frequently used treatment options. Stent placement was more common for grade 3 or 4 dysphagia. Delivery of endoscopic palliative therapy varied by region of residence (from 18% to 38% of patients, p < 0.001) but not by deprivation category. Complications were recorded in 16% of patients (155 of 948). Overall survival was 40% (95% confidence interval [CI], 36-43) at 6 months, 17% (95% CI, 14-19) at 12 months, and 10% (95% CI, 8-12%) at 18 months.

CONCLUSIONS

These data define the reality of endoscopic palliative therapy for patients with advanced esophageal or gastric cancer and provide a baseline against which future improvements in care can be measured.

Definitive chemoradiation in patients with inoperable oesophageal carcinoma

We performed a retrospective study of 90 consecutive cases with inoperable carcinoma of the oesophagus treated with definitive chemoradiation at a single cancer centre between 1995 and 2002. For the last 4 years, 73 patients have received therapy according to an agreed protocol. This outpatient-based regimen involves four cycles of chemotherapy, cycles 3 and 4 given concurrently with 50 Gy external beam radiotherapy (XRT) delivered in 25 fractions over 5 weeks. Cisplatin 60 mg m(-2) day(-1) is given every 3 weeks together with continuous infusional 5-fluorouracil 300 mg m(-2) day(-1), reduced to 225 mg m(-2) day(-1) during the XRT. In all, 45 (50%) patients suffered one or more WHO grade 3/4 toxicity, grade 3 in 93% cases. Patients received more than 90% of the planned chemoradiation schedule. The median overall survival was 26 (15, >96) months, 51% (41, 64) and 26% (13, 52) surviving 2 and 5 years, respectively. Advanced stage, particularly T4 disease, was associated with a worse prognosis. Patients considered not suitable for surgery for reasons other than their disease, mainly co-morbidity, had a significantly better outcome, median survival 40 (26, >96) months, 2- and 5-year survivals 67% (54, 84) and 32% (13, 79), respectively (P<0.001). This schedule is a feasible, tolerable and effective treatment for patients with oesophageal cancer considered unsuitable for surgery.

Estimation of an optimal radiotherapy utilization rate for gastrointestinal carcinoma

BACKGROUND

Radiotherapy utilization rates for cancer vary widely, both within and between countries. The optimal proportion of patients with gastrointestinal malignancies who should receive at least one course of radiotherapy at some time during their illness is an important benchmark.

METHODS

The authors studied treatment guidelines and treatment reviews to identify the indications for radiotherapy for patients with gastrointestinal malignancies. Optimal radiotherapy utilization trees were constructed to show the clinical attributes of patients with gastrointestinal carcinomas who will benefit from radiotherapy. Epidemiologic incidence data for each of these clinical attributes were obtained to calculate the optimal proportion of all patients with gastrointestinal malignancies for whom radiotherapy was considered appropriate. Optimal rates of radiotherapy use were compared with actual rates in population-based studies to assess any discrepancies between actual and optimal radiotherapy utilization rates.

RESULTS

Radiotherapy was indicated in 80% of patients with esophageal carcinoma, 68% of patients with gastric carcinoma, 57% of patients with pancreatic carcinoma, 13% of patients with carcinoma of the gallbladder, 0% of patients with hepatic carcinoma, 14% of patients with colon carcinoma, and 61% of patients with rectal carcinoma. The actual radiotherapy utilization rates for most of these gastrointestinal malignancies fell well short of optimal rates, which were derived from evidence-based treatment guidelines.

CONCLUSIONS

It is possible to model optimal radiotherapy utilization using published treatment guidelines and existing incidence data. There was a discrepancy between the optimal and actual rates of radiotherapy utilization for patients with carcinomas of the esophagus, stomach, pancreas, and rectum. Strategies to implement evidence-based clinical guidelines are recommended.

Open-access gastroscopy is associated with improved outcomes in gastric cancer

OBJECTIVE

To examine whether patients with gastric cancer diagnosed via open-access gastroscopy (OAG) differ in their outcomes compared with patients referred conventionally to outpatient clinics or as acute emergencies.

DESIGN AND SETTING

Prospective observational study in the gastroenterology and surgical units of a large district general hospital.

PARTICIPANTS

One hundred consecutive patients with gastric adenocarcinoma.

MAIN OUTCOME MEASURES

Data were collected prospectively and subdivided into two groups according to whether the patients were referred via the open-access route or the conventional route.

RESULTS

Diagnostic delay from onset of symptoms was shorter for patients referred via OAG compared with those referred conventionally. Stages of disease were significantly earlier in patients referred via OAG compared with patients referred conventionally. Potentially curative resection was significantly more likely following OAG than after conventional referral. Cumulative five-year survival for patients referred via OAG was 30% compared with 12% after conventional outpatient referral and 13% after acute referral. Multivariate analysis revealed three factors to be associated with survival: stage of disease, distant metastases and referral via the open-access route.

CONCLUSIONS

Gastric cancers presenting at OAG were diagnosed at an earlier stage than cancers diagnosed after conventional referral. This led to a higher proportion of potentially curative resections and better five-year survival.

Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study

OBJECTIVE

To evaluate the effect of comorbidity and other risk factors on postoperative mortality and morbidity in patients undergoing major oesophageal and gastric surgery.

DESIGN

Multicentre cohort study with data on postoperative mortality and morbidity in hospital.

DATA SOURCE AND METHODS

The ASCOT prospective database, comprising 2087 patients with newly diagnosed oesophageal and gastric cancer in 24 hospitals in England and Wales between 1 January 1999 and 31 December 2002. Multivariate logistic regression analysis was used to model the risk of death and postoperative complications.

RESULTS

955 patients underwent oesophagectomy or gastrectomy. Of these, 253 (27%) were graded ASA III or IV, and 187 (20%) had a high physiological POSSUM score (>or= 20). Operative mortality was 12% (111/955). Physiological POSSUM score, surgeon's assessment, type of operation, hospital case volume, and tumour stage independently predicted operative mortality. Medical complications were associated with higher physiological POSSUM scores and ASA grade, oesophagectomy or total gastrectomy, thoracotomy, and radical nodal dissection. Stage and additional organ resection predicted surgical (technical) complications.

CONCLUSIONS

Many patients undergoing surgery for gastro-oesophageal cancer have major comorbid disease, which strongly influences their risk of postoperative death. Technical complications do not seem to be influenced by preoperative factors but reflect the extent of surgery and perhaps surgical judgment. Detailed prospective multicentre cooperative audit, with appropriate risk adjustment, is fundamental in the evaluation of cancer care and must be properly resourced.

Improvement in treatment results and long-term survival of patients with esophageal cancer: impact of chemoradiation and change in treatment strategy

OBJECTIVE

To identify prognostic factors and reasons for improved survival over time in patients with esophageal cancer.

SUMMARY BACKGROUND DATA

Management strategies for esophageal cancer have evolved with time. The impact of chemoradiation in the overall treatment results has not been adequately studied.

METHODS

From 1990 to 2000, 399 (62.4%) of 639 patients with intrathoracic squamous cancers underwent resection. Two study periods were analyzed: period I (01/1990-06/1995), and period II (07/1995-12/2000); during period II, chemoradiation was introduced. Prognostic factors were identified by multivariate analysis and the 2 periods compared.

RESULTS

Hospital mortality rate after resection decreased from 7.8% to 1.2%, P = 0.002. Five favorable prognostic factors were identified: female gender (female vs. male, HR = 0.66), infracarinal tumor location (infra vs. supra-carinal, HR = 0.63), low pTNM stage (III/IV vs. 0/I/II/T0N1, HR = 1.76), pM0 stage (M1a/b vs. M0, HR = 1.56), and R0 category (R1/2 vs. R0, HR = 2.49). Median survival was 15.8 and 25.6 months in periods I and II, respectively, P = 0.02. More R0 resections were evident in period II, being possible in 63% (period I) and 79% (period II) of patients, P = 0.001. This was attributed to tumor downstaging by chemoradiation and more stringent patient selection for resection in period II. Performing less R1/2 resections in period II coincided with using primary chemoradiation in treating advanced tumors. In patients treated without resection, survival also improved from 3 (period I) to 5.8 months (period II), P < 0.01.

CONCLUSIONS

Survival has improved; chemoradiation enabled better patient selection for curative resections and also resulted in more R0 resections by tumor downstaging. This treatment strategy led to overall better outcome for the whole patient cohort, even in those treated by nonsurgical means.

Special interest radiology improves the perceived preoperative stage of gastric cancer

AIM

The aim of this study was to compare the accuracy of spiral computed tomography (CT) performed by a specialist radiologist within a multi disciplinary team (MDT) framework with that of radiologists working outside of this framework.

MATERIALS AND METHODS

One hundred and ten patients [median age 70 (35-86)yr, 71m] underwent either a preoperative CT performed by the MDT specialist consultant radiologist (n=60) or a CT performed by one of 13 other consultant radiologists (n=50). The strength of the agreement between the CT stage and the histopathological stage was determined by the weighted Kappa statistic (Kw).

RESULTS

Sensitivity for T, N and M stage were 64%, 65% and 25% for MDT specialist CT, compared with 24%, 24% and 5% for control CT. Specificity for T, N and M stage were 68%, 59% and 95% for MDT specialist CT compared with 79%, 94% and 93% for control CT. Kw for T, N and M stage were 0.314, 0.350 and 0.255 for MDT specialist CT compared with 0.088, 0.102 and -0.019 for control CT. Unsuspected metastases were found in 12 patients staged by MDT specialist CT compared with 19 patients staged by control CT (Chi2=4.366, df=1,p =0.037).

CONCLUSION

Improved patient selection for surgery should maximize use of limited resource.

A multicentre, randomised phase III trial comparing protracted venous infusion (PVI) 5-fluorouracil (5-FU) with PVI 5-FU plus mitomycin C in patients with inoperable oesophago-gastric cancer

BACKGROUND

This randomised study compared protracted venous infusion (PVI) fluorouracil (5-FU) with PVI 5-FU plus mitomycin C (MMC) in patients with advanced oesophago-gastric cancer.

PATIENTS AND METHODS

Two hundred and fifty-four patients with adenocarcinoma, squamous cell carcinoma or undifferentiated carcinoma involving the oesophagus, oesophago-gastric junction or the stomach were randomised. The major end points were tumour response, survival, toxicity and quality of life.

RESULTS

The median age of patients treated was 72 years and the two arms were well-balanced for baseline demographic factors. The overall response rate was 16.1% [95% confidence interval (CI) 9.5% to 22.7%] in patients treated with PVI 5-FU alone compared with 19.1% (95% CI 12.0% to 26.0%) for those treated with PVI 5-FU plus MMC (P = 0.555). Median time to treatment failure was 3.9 months for PVI 5-FU and 3.8 months for PVI 5-FU plus MMC (P = 0.195). Median survival was 6.3 months for PVI 5-FU and 5.3 months for PVI 5-FU plus MMC (P = 1.0). Toxicity was mild for both treatments. Symptomatic benefit measured by improvement in pain control, weight loss, dysphagia and oesophageal reflux was observed in over 64% of patients in each arm. Quality of life scores were comparable in each arm.

CONCLUSIONS

PVI 5-FU is a safe, effective form of palliation for patients with advanced oesophago-gastric cancer although the addition of MMC adds little extra benefit.

Esophageal carcinoma: surgery, radiotherapy, and chemotherapy

Several new developments in the potentially curative therapy of esophageal cancer have drawn attention over the past year. There is a potential benefit of centralization of esophagectomies in dedicated centers. Early mucosal lesions are increasingly treated by local ablative therapy. Tumors invading the submucosa are preferably treated by surgical resection. There is ongoing controversy about the optimal surgical approach. Positron emission tomography scanning is a promising tool in the preoperative work-up but needs critical evaluation. The question of whether chemoradiation with voice preservation (followed by salvage surgery in case of tumor recurrence) can replace pharyngolaryngectomy in patients with cervical esophageal cancer is still unanswered. A review of eight randomized trials demonstrated that chemoradiation as primary treatment of esophageal cancer provides an absolute reduction of mortality. The addition of new drugs like paclitaxel and irinotecan into induction regimens for the treatment of advanced disease results in higher response rates but also in increased toxicity. Preoperative radiotherapy as single modality treatment does not improve overall survival, whereas the benefit of preoperative chemotherapy and chemoradiation has not been proven unequivocally. Several retrospective studies with a small number of patients suggest that local response parameters like pathologic complete response and downstaging of regional lymph node (N) status are correlated with longer survival.

Cohort study in South and West England of the influence of specialization on the management and outcome of patients with oesophageal and gastric cancers

BACKGROUND

To evaluate specialization in National Health Service (NHS) cancer care, volume-outcome relationships were examined.

METHODS

This was a cohort study of 1512 patients with oesophageal or gastric cancer in 23 acute NHS hospitals. Outcomes were survival time and operative (30 day) mortality. Multiple regression analysis was performed, adjusted for diagnoses, prognoses and treatments.

RESULTS

For oesophageal cancer, the operative mortality rate decreased by 40 per cent (odds ratio 0.60 (95 per cent confidence interval (c.i.) 0.36 to 0.99 per cent); P = 0.047) for each increase of ten patients in doctors' annual surgical caseloads, and the risk of death decreased by 8 per cent (hazard ratio 0.92 (95 per cent c.i. 0.85 to 0.99); P = 0.021) for each increase of ten patients in doctors' annual caseloads. For gastric cancer, the operative mortality rate decreased by 41 per cent (odds ratio 0.59 (95 per cent c.i. 0.32 to 1.07)) for each increase of ten patients in doctors' annual surgical caseloads, and the risk of death decreased by 7 per cent (hazard ratio 0.93 (95 per cent c.i. 0.89 to 0.98); P = 0.009) for each increase of ten patients in hospitals' annual caseloads. Patients of higher-volume doctors were more likely to receive most investigations and treatments, independently of presenting features.

CONCLUSION

The study supports concentration of services for oesophageal and gastric cancers. Specialization of doctors and their teams is at least as important as specialization of hospitals.

Hospital volume and post-operative mortality after resection for gastric cancer

AIMS

In low-volume hospitals, expertise in gastric surgery is difficult to maintain because of the decreasing incidence of gastric cancer and the fall of surgery for ulcer disease. We evaluated the prognostic impact of hospital volume on post-operative mortality (POM) in a consecutive series of 1978 patients.

METHODS

Information on patients undergoing resection for gastric cancer in the period 1987-97 was retrieved from the Rotterdam Cancer Registry. The relationship between hospital volume and POM was analysed by logistic regression, adjusting for other prognostic factors.

RESULTS

POM was 7.9% on average but varied between the 22 hospitals from 3.1% to 15.1% (P=0.15). Hospital volume had no prognostic influence (P=0.74). Prognostic factors were age (70-79 years odds ratio (OR)=3.8, 80+ years OR=6.0), sex (male OR=1.7), stage (IV OR=1.8) and (partial) gastrectomy for cardia cancers (OR=2.0).

CONCLUSION

Variation in POM between hospitals was large but not related to hospital volume. For cardia cancer, POM rates were lower after oesophagogastrectomy.

Prevention of the neoplastic progression of Barrett's oesophagus by endoscopic argon beam plasma ablation

BACKGROUND

Patients with Barrett's oesophagus have a risk of approximately 1 per 100 patient-years for the development of oesophageal adenocarcinoma. Endoscopic ablation of Barrett's oesophagus has been shown to lead to the regrowth of a 'neo' squamous epithelium if gastro-oesophageal reflux is controlled, but the incidence of subsequent tumour formation is unknown.

METHODS

The follow-up of 55 patients who underwent endoscopic ablation of Barrett's oesophagus by argon beam plasma coagulation (ABPC) is reported. Of the 55 patients, nine had low-grade dysplasia, nine had high-grade dysplasia and the remainder had non-dysplastic Barrett's metaplasia. Twelve patients had reflux control by antireflux surgery and the remainder received proton pump inhibitor therapy. Barrett's metaplasia was ablated by ABPC to within 2 cm of the gastro-oesophageal junction.

RESULTS

To date, one patient has died and one patient was unable to complete treatment. The remaining patients were followed by regular endoscopic surveillance for a mean of 38.5 months to give a total follow-up of 173.5 patient-years. No malignancy has developed in any patient during follow-up.

CONCLUSION

The absence of malignant complications in this study of prophylactic ablation of long-segment Barrett's oesophagus strengthens the argument for endoscopic ablation in the prevention of oesophageal adenocarcinoma.