The current status of combined modality treatment containing chemotherapy in patients with esophageal cancer.

In this issue of the International Journal of Radiation Oncology Biology Physics, Whittington et al. (17) report on a retrospective analysis of the results of single and combined modalities in patients with adenocarcinoma of the esophagus and esophago-gastric (GE) junction. They concluded that combined modality therapy of surgery, radiotherapy, and chemotherapy reduced the risk of local recurrence, and was found to extend the median survival of patients with this disease without excessive toxicity. The results of this important paper will attract attention, considering the poor prognosis reported in this disease, and the ongoing efforts by the cooperative groups to activate protocols investigating the role of combined modality treatment. All the published combined modality trials containing chemotherapy in patients with esophageal cancer are either single institution or cooperative group Phase II studies, or retrospective analyses of the results of various therapeutic approaches in this disease as in the above-mentioned article. Two randomized prospective clinical trials have been conducted: one study was just completed by the Eastern Cooperative Oncology Group (ECOG), and the second trial is ongoing, initiated by the Radiation Therapy Oncology Group (RTOG) and later activated by other cooperative groups. Cancer of the esophagus is a rare tumor in the United States; it represents about 1% of the estimated newly diagnosed cancer cases in 1990 (13). About 10,600 estimated new cases in the United States were diagnosed in 1990, with a male to female ratio of about 2: 1. The estimated death from cancer of the esophagus in 1990 will be about 9,500, which represents 1.8% of the estimated total deaths from cancer in the United States. The most common histopathology is squamous cell cancer, which constitutes about 90% to 95% of all cancer cases. Adenocarcinomas of the esophagus and GE junction represent the rest of the cases. Adenocarcinoma is most common in the distal third of the esophagus (5). The trend of 5-year survival rates of all stages of cancer of the esophagus has not changed between 1960 and 1979; it is about 5% in white patients and 3% in black patients ( 13). The relative 5-year survival rate between 1980-l 985 is estimated to be 8% in white patients and 6% in black patients ( 13). One would wonder if this slight but definite improvement in survival is caused by the introduction of combined treatment modality in this disease, the early diagnosis of the cancer, or both. Survival of patients with esophageal cancer will depend on the stages of the disease at treatment, location of the cancer, histopathology, performance status of these patients, and possibly the type of treatment used. Between 1974 and 1985, the 5-year survival rates of all stages was about 6%; for localized disease it was 13% in white and 10% in black patients, for regional involvement it was about 4%, and in patients with distant metastases it was 1% ( 13). The standard therapy for esophageal cancer is either surgery, radiation therapy, or both. The overall results of such treatments have been poor and not acceptable. The majority of patients with esophageal cancer are considered unresectable, either at the time of preoperative assessment or at surgery. This is because of the poor condition of these patients, cardio-pulmonary problems, location of the cancer, or the regional and/or distant spread of the cancer. The type and extent of surgical resection may differ between investigators, or may depend on the end results of palliation or cure. The morbidity and mortality rates from this procedure are high, and the expected end results of long-range palliation or survival are poor. The two major problems from esophageal resection and anastomosis are leakage and stricture. From review of the literature of patients who had sur-