| Abstract: |
The role of combined modality therapy including chemotherapy as primary treatment for newly diagnosed patients with esophageal carcinoma is based on the disease's high propensity for metastasis. Chemotherapeutic regimens capable of inducing major objective responses in 40-60% of patients with localized cancers have been developed. Toxicity has been tolerable. However, the majority of responses are only partial; there is intense interest in the development of newer regimes capable of inducing complete remissions in a significant number of patients. In this regard, Paclitaxel has recently been identified as an active drug. Radiation therapy as an alternative local regional approach to surgery has been explored for many years. When used as a single modality, however, the duration of palliation achieved has been unsatisfactory and cure rare. There are ample theoretic grounds for combining chemotherapy and concurrent radiation. Clinical phase I and II trials have led to the development of combinations of chemotherapy plus radiation, with acceptable toxicities. Most recently, definitive phase III trials have been performed indicating that (at least for patients with epidermoid carcinoma of the esophagus) chemotherapy plus concurrent radiation has a survival advantage when compared to radiation alone. Newer regimens and better radiation therapy treatment planning are under intense investigation to further improve these results. The obvious question of the role of surgery versus the role of radiation to control local regional disease should now be addressed in random assignment trials. It is crucial that in these studies the patient populations are balanced; as opposed to previous retrospective comparisons, radiation therapy plus concurrent chemotherapy patients should also have localized disease that is potentially resectable and be fit to undergo either of the two planned local regional approaches. Whether or not chemotherapy should also be included in the surgery arm will depend on the result of phase III national studies currently underway in the United States and in other countries. |
