Radiotherapy versus surgery within multimodality protocols for esophageal cancer – A meta-analysis of the randomized trials
A partir d'une revue de la littérature, cette méta-analyse (6 essais randomisés, 929 cas) compare l'efficacité de différents protocoles combinant ou non une radiothérapie et une intervention chirurgicale dans le traitement du cancer de l'oesophage
During recent years, the curative potential of radiotherapy versus surgery for esophageal cancer was investigated in randomized trials. A PubMED®, Medline®, and Web of Science® search identified six randomized studies comparing definitive (chemo-) radiotherapy with either surgery alone or surgery+/−induction treatment for patients (n=929) with potentially resectable, mainly thoracic squamous cell (810/929pts.) esophageal cancer. In three of the studies (440pts.), resection alone was planned in the surgery arm, in three others induction chemoradiotherapy up to a total dose of 30–46Gy followed by resection was scheduled (489pts.). In the definitive radiation arms (+/−chemotherapy, conservative arm) total radiation doses of 45–71Gy with differing fractionation schedules were planned. Summary hazard ratios for survival, loco-regional control and treatment related mortality were calculated from intent-to-treat data. Overall survival was equivalent between surgery and definitive chemoradiotherapy (hazard ratio (HR) 0.98 [95% CI 0.8–1.2, p=0.84]). There was a trend to more cancer related deaths in the definitive radiation+/−chemotherapy arms (HR 1.19 [0.98–1.44], p=0.07), predominantly due to a higher risk of loco-regional progression (HR 1.54 [1.2–1.98], p=0.0007) but treatment related mortality was lower in the conservative arms (HR 0.16 [0–0.89], p=0.001). Protocol compliance was better in the conservative arms. A high concurrent risk of distant metastases (HR 0.72 [0.52–1.01], p=0.06) worsens the cancer specific survival of the loco-regionally controlled, resected patients with squamous cell cancers. The similar outcome in survival suggests that the safer approach of radiochemotherapy is a reasonable choice especially in comorbid patients with esophageal squamous cell carcinoma.