ASCO Releases Clinical Guidelines for the Treatment of Patients with Advanced Esophageal Cancer

2021 Year in Review - Gastrointestinal Cancer

Recommendations for the clinical management of patients with advanced esophageal cancer and gastroesophageal junction adenocarcinoma were released by an expert panel.

Esophageal cancer is the sixth most common cause of cancer globally. There are 2 main types of esophageal cancer: adenocarcinoma and squamous-cell carcinoma (SCC). SCC is the most common type of esophageal cancer found in East Asia and the Middle East. Adenocarcinoma is more common in Western countries. Locally advanced esophageal cancer tumors are defined as tumors that invade local structures or involve the regional lymph nodes, but there are no metastases with this cancer type. Although surgery has been the main curative treatment for locally advanced esophageal cancer, it has a poor prognosis, especially for SCC. As a result, research is ongoing for additional effective therapies, including chemotherapy and radiation therapy.

An expert panel convened by the American Society of Clinical Oncology performed a literature review of recent evidence for therapy options to develop an evidence-based clinical practice guideline to aid clinicians in making appropriate management decisions for patients with locally advanced esophageal cancer and resectable Siewert type 1 and 2 gastroesophageal junction adenocarcinoma. Seventeen randomized controlled trials were reviewed, and clinical questions were addressed to incorporate considerations for neoadjuvant or adjuvant therapy with or without surgery in light of the 2 esophageal cancer types.

The panel strongly recommended multimodal therapy for patients with locally advanced esophageal adenocarcinoma. However, surgery may be more appropriate for patients with low-risk, well-differentiated lesions. It is strongly recommended that patients with locally advanced esophageal adenocarcinoma be offered preoperative chemoradiotherapy or perioperative chemotherapy, but clinicians should keep in mind that chemoradiotherapy may contribute to more severe postoperative complications than perioperative chemotherapy. If a less extensive surgery is necessary, or if surgery results in inadequate margins, radiation therapy may be of benefit for the patient. Preoperative chemotherapy should be considered for patients who are unable to undergo radiation or postoperative chemotherapy. For patients unable to undergo surgery, chemoradiotherapy is recommended.

It is strongly recommended that patients with locally advanced esophageal SCC should be offered preoperative chemoradiotherapy or chemoradiotherapy without surgery. If a patient has a complete response to chemoradiotherapy, they may be a candidate for a salvage esophagectomy. This recommendation is based on evidence from an ongoing clinical trial. If radiation therapy is not possible, preoperative chemotherapy should be considered. It is recommended that patients with cervical esophageal tumors receive chemoradiotherapy. If cervical esophageal tumors persist or recur, then surgery should be considered, taking into account the patient’s age, comorbidities, and preferences along with caregiver support.

Source: Shah MA, Kennedy EB, Catenacci DV, et al. Treatment of locally advanced esophageal carcinoma: ASCO guideline [published correction appears in J Clin Oncol. 2020;38:3976]. J Clin Oncol. 2020;38:2677-2694.

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