According to a study published in the journal Lancet Gastroenterology and Hepatology, palliative radiotherapy is slightly less effective but much less toxic than palliative chemoradiotherapy for dysphagia in patients with advanced esophageal cancer.
"Based on the findings, we see that radiotherapy is a safe and well tolerated palliation tool for patients with symptoms from advanced esophageal cancer when compared to chemoradiotherapy,” said Dr. Paolo De Ieso from Alan Walker Cancer Care Center, Darwin, Northern Territory, Australia.
Malignant dysphagia in the palliative setting has been treated with chemotherapy alone, endoscopic debulking or stenting, radiotherapy, or a combination of modalities including chemoradiotherapy.
Dr. De Ieso and colleagues compared the efficacy and toxicity profile of chemoradiotherapy with that of radiotherapy alone for palliation of malignant dysphagia in a randomized controlled trial involving 220 patients with advanced esophageal cancer at 22 Australian hospitals.
They defined dysphagia relief as improvement of at least 1 point on the Mellow scale at 9 weeks that was maintained 4 weeks later. Complete dysphagia relief they defined as improvement to Mellow score 0 at the same intervals.
More patients in the chemoradiotherapy group (45%) than in the radiotherapy group (35%) experienced dysphagia relief (P=0.13), and complete dysphagia relief was slightly more common with chemoradiotherapy (29%) than with radiotherapy (24%) alone (P=0.44), according to the study report.
Estimated median time from start of therapy to any relief or in the median duration of any relief and median dysphagia progression-free survival from randomization was almost similar in the two groups, with only 5% of patients in the chemoradiotherapy group and 7% in the radiotherapy group surviving without progression at 1 year.
More than twice as many chemoradiotherapy as radiotherapy patients (36% vs. 16%) experienced grade 3-4 acute toxicity, but late toxic effects did not differ between the randomized groups among patients surviving for more than 90 days.
“Our prognostic factor analyses showed that, for patients with minimal bodyweight loss, with or without metastases, palliative radiotherapy or chemoradiotherapy for 2-3 weeks provides relief from malignant dysphagia in about 50% of cases, and median overall survival is about 11 months,” the researchers noted.
“However, patients with 5% or more bodyweight loss and metastatic disease have a much poorer prognosis (dysphagia relief rate of 34% and median overall survival of about 5 months), highlighting the importance of patient selection and individualization of treatments in this patient population,” they added.
“Despite having an established role in the radical or curative setting, chemoradiotherapy does not appear to greatly affect the key palliative endpoints, including dysphagia relief, at the expense of greater toxicity,” Dr. De Ieso said.
“Modern radiotherapy can be delivered with minimal toxicity and minimal disruption of a patient’s life and has applicability in a number of palliative settings,” he added.
“Esophageal cancer remains a challenging disease to treat,” wrote Dr. Thomas D.L. Crosby from Velindre Cancer Center, Cardiff, UK, in a related editorial. “The fact that most of our patients do not survive long term after potentially curative surgery or chemoradiotherapy or respond to palliative chemotherapy or radiotherapy, or both, according to RECIST criteria or dysphagia-free survival as defined in the current study suggests we still have a long way to go to achieve that holy grail of personalized oncology: selecting the right treatment for the right patient at the right time.”