Radiotherapy without chemo may be best for dysphagia in advanced esophageal cancer

Last Updated: 2017-12-22

By Will Boggs MD

NEW YORK (Reuters Health) - Palliative radiotherapy is slightly less effective but much less toxic than palliative chemoradiotherapy for dysphagia in patients with advanced esophageal cancer, according to results from a randomized trial.

"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," Dr. Paolo De Ieso from Alan Walker Cancer Care Center, Darwin, Northern Territory, Australia, told Reuters Health by email. "We would advocate this unimodality treatment in the first instance, for patients with malignant dysphagia. These decisions should always be made in the context of a multidisciplinary team discussion, where support for nutrition and the role of systemic therapy and palliation of symptoms are also defined."

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 than with radiotherapy alone (29% vs. 24%; P=0.44), according to the December 13 Lancet Gastroenterology and Hepatology online report.

The groups did not differ significantly in the median time from start of therapy to any relief or in the median duration of any relief.

Estimated median dysphagia progression-free survival from randomization was 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 note. "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."

Patient-assessed quality of life will be reported separately.

"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. "Further trials should investigate more novel agents and strategies in patients that may have relatively advanced local disease in the absence of metastases, and thus considered for radical treatment."

"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 said. "I hope other clinicians are encouraged to perform research in this palliative setting, focusing on the patient experience rather than longevity as an indicator of success in a patient population where symptom control is often their primary consideration."

"Esophageal cancer remains a challenging disease to treat," writes 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."

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Lancet Gastroenterol Hepatol 2017.