Does adjuvant chemo improve survival in gastroesophageal cancer?

Reuters Health Information: Does adjuvant chemo improve survival in gastroesophageal cancer?

Does adjuvant chemo improve survival in gastroesophageal cancer?

Last Updated: 2017-09-29

By Marilynn Larkin

NEW YORK (Reuters Health) - In patients with locally advanced gastroesophageal adenocarcinoma treated with preoperative chemoradiation and resection, adjuvant chemotherapy is associated with improved overall survival, researchers in Texas say.

"Currently there are no data to guide the use of adjuvant chemotherapy after chemoradiation and surgery in patients with gastroesophageal cancer," Dr. Matthew Porembka of the University of Texas Southwestern Medical Center, in Dallas, told Reuters Health.

"Current chemoradiation protocols often administer less systemic chemotherapy, possibly increasing the risk of developing recurrence," he said by email. "The use of adjuvant therapy has been selective, most often being offered to patients who were believed to possess a higher risk of recurrence."

To assess the value of postoperative adjuvant chemotherapy versus observation, Dr. Porembka and colleagues retrospectively analyzed data from 10,086 patients (mean age, 61; 88% men) diagnosed with clinical stage T1N1-3MO or T2-4NO-3MO adenocarcinoma of the distal esophagus or gastric cardia between 2006 and 2013.

In all, 9,272 patients underwent postoperative observation and 814 had adjuvant chemotherapy, as reported in JAMA Oncology, online September 21.

Compared with those in the observation group, patients who received adjuvant chemotherapy were younger (31% vs. 21% age 18-54), were more likely to have advanced disease (62% vs. 46% stage T3/4 and 72% vs. 39% node-positive), and had shorter postoperative inpatient stays (13% vs. 20% stayed >2 weeks).

When the team compared outcomes, using propensity-score matching, for 732 patients in the adjuvant chemotherapy group and 3,660 patients in the observation group, adjuvant chemotherapy was associated with improved overall survival (median, 40 vs. 34 months).

Overall survival at one, three and five years was 88%, 47%, and 34% in the observation group, and 94%, 54%, and 38% in the adjuvant chemotherapy group, respectively.

Further, adjuvant chemotherapy was associated with a survival benefit compared with postoperative observation in most patient subgroups (i.e., tumor-specific variables), according to the authors.

"The survival benefit was largest, although not statistically significant, in patients with pathologic complete response . . . - a relevant finding," they note, "given that this patient group has a 23% risk of recurrence."

Dr. Porembka said that because this is a retrospective study, "the ability to draw definitive conclusions is limited and additional prospective trials are needed to confirm the results," Dr. Porembka said. "In addition, future studies that help us to better understand an individual patient's recurrence risk will be useful in tailoring the use of adjuvant therapy."

Dr. Elizabeth Smyth of Royal Marsden Hospital, London and Sutton, UK, coauthor of a related commentary, told Reuters Health, "These results are intriguing, but as a retrospective study, not practice changing."

"Neoadjuvant chemoradiotherapy before surgery is one frequently used treatment for patients with resectable gastroesophageal cancer," she said by email. "However, unfortunately, many patients treated with chemoradiotherapy and surgery will ultimately relapse and die from their cancer."

"As the dose of chemotherapy used with chemoradiotherapy is relatively low, it is possible that adding more systemic chemotherapy could improve survival for these patients," she acknowledged. "However, there are challenges to treating patients with chemotherapy after surgery to remove the esophagus or stomach (since) many patients have nutritional difficulties and are not able to tolerate chemotherapy after their operation."

"It is possible that increasing the intensity of chemotherapy before surgery could also be helpful, and this might be a more pragmatic choice," she noted. "However, any new treatment regimen is required to demonstrate efficacy in a clinical trial prior to changing treatment standards."

"The international TOPGEAR study (http://bit.ly/2ydyoRA) is currently evaluating whether perioperative chemotherapy plus chemoradiotherapy and surgery improves survival compared to perioperative chemotherapy plus surgery alone," she added. "The results of this trial will help to answer this question."

SOURCES: http://bit.ly/2x0qXIo and http://bit.ly/2wZVKFo

JAMA Oncol 2017.

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