Positive outcomes.

Top Line: Is neoadjuvant chemoradiation or chemotherapy best for locally advanced esophageal squamous cell carcinoma?

The Study: The landmark Western trials for esophageal cancer included mostly adenocarcinoma. Esophageal squamous cell carcinoma (ESCC) is more common in the East, and a series of Chinese trials have asked the important neoadjuvant therapy questions in the ESCC population. In 2018, NEOCRTEC5010 showed that neoadjuvant chemoradiation (cisplatin, vinorelbine, and 40 Gy) improved median overall survival from 67 to 100.1 months compared to surgery alone in patients with locally advanced ESCC thanks to a 43% pCR rate. CMISG1701 was a randomized trial that compared neoadjuvant chemoradiation and neoadjuvant chemotherapy alone for locally advanced ESCC. 264 patients with cT3-4aN0-1 ESCC received either 40 Gy in 20 fractions with 4 cycles of concurrent cisplatin (25 mg/m2) and paclitaxel (50 mg/m2) or 2 cycles of cisplatin (75 mg/m2) and paclitaxel (175 mg/m2) without radiation. All patients then underwent minimally invasive esophagectomy. Last year, we learned that post-op complications and morbidity were similar between arms, but that nCRT resulted in a significantly higher pCR rate (28% v 3%), fewer involved nodes (66% ypN0 v 46%), and more significant downstaging. Here we have survival outcomes. At 3 years, overall survival was 64% with nCRT compared to 55% with nCT, but despite this nearly 10% absolute improvement, the difference was not statistically significant. Median progression-free survival was 47 v 34 months.

TBL: This trial did not show a significant survival improvement with nCRT over nCT for ESCC, but with a trend to better survival outcomes, clearly superior disease response, and no increase in morbidity, are we really left uncertain of the preferred neoadjuvant treatment strategy? | Tang, Ann Oncol 2022