Endoscopic Therapy a Good Option in Early Esophageal Cancer

Megan Brooks

November 21, 2013

Endoscopic therapy is a good option for early esophageal adenocarcinoma, with overall survival and cancer-specific survival on par with surgery, results from a large population-based study confirm.

"There is growing evidence from single expert centers that endoscopic therapy is effective for early esophageal cancer," lead author Michael B. Wallace, MD, a gastroenterologist at Mayo Clinic Florida in Jacksonville, told Medscape Medical News.

"These new data provide evidence that this benefit is being realized at a national level using a national representative sample. They also demonstrate that endoscopic therapy is increasingly being used, although it remains much less common than surgery," Dr. Wallace said.

The study was published in the November issue of Clinical Gastroenterology and Hepatology.

"Now Part of Our Armamentarium"

"Endoscopic therapy for very early, very superficial esophageal cancer is now part of our armamentarium," said Amit Bhargava, MD, esophageal cancer expert and thoracic surgeon at Montefiore Medical Center, and assistant professor in the Department of Cardiovascular and Thoracic Surgery at Albert Einstein College of Medicine Bronx, New York. He was asked by Medscape Medical News to comment, and was not involved in the study.

"This paper provides greater numbers to look at and really confirms what has already been shown," added Dr. Bhargava.

Dr. Wallace and colleagues identified 1618 patients with Tis (high-grade dysplasia), T1a (invades lamina propria or muscularis mucosae), or T1b (invades submucosa) esophageal cancer treated from 1998 to 2009 in the National Cancer Institute Surveillance, Epidemiology and End Results (SEER) database.

The researchers found that 306 patients (19%) were treated with endoscopic therapy and 1312 (81%) were treated with surgery. The use of endoscopic therapy increased progressively, from 3% in 1998 to 29% in 2009, they report.

Endoscopic therapy was more common in people older than 65 years, in people diagnosed more recently (from 2006 to 2009 vs 1998 to 2001), and in the absence of submucosal invasion.

In unadjusted analysis, patients treated with surgery had better overall survival at 5 years than those treated with endoscopic therapy (70% vs 58%; P = .003), although 5-year cancer-specific survival was similar in the 2 groups (82% vs 78%; P = .26).

However, after adjustment for patient and tumor factors, overall survival times were similar in patients treated with endoscopic therapy and those treated with surgery (hazard ratio [HR], 1.21; 95% confidence interval [CI], 0.92 - 1.58), as were esophageal-cancer-specific survival times (HR, 0.74; 95% CI, 0.49 - 1.11).

"This finding was also true for the subgroups of tumor stage Tis/T1a and T1b after adjusted multivariable regression analyses," the researchers note.

"Patients with high-grade dysplasia and early (T1a) esophageal adenocarcinoma are the best suited for endoscopic therapy," Dr. Wallace told Medscape Medical News. "A subset of those with T1b (invasion into submucosa) may also respond well to endoscopic therapy if they are at a low risk of lymph node metastases."

"The most important thing is careful staging of the patients," Dr. Bhargava explained. "What we don't know from this study is whether some of the patients with T1b cancers — which really are appropriately treated with surgery because of a high incidence of nodal disease — did go on to surgery. It's possible the reason there is equivalent survival in that group is because those patients did get surgery or some other adjuvant therapy (chemotherapy and radiation), which would probably be appropriate for T1b patients who didn't get surgery."

Dr. Wallace said he and his colleagues are "exploring methods to provide esophagus-preserving endoscopic therapy even for those with more advanced tumors. However, this is not yet the standard of care."

Dr. Bhargava added that "appropriate patients with very early superficial esophageal cancer should be offered endoscopic therapy. Esophagectomy is a huge surgery; whether we do it using minimally invasive technique, which I do, or an open procedure, it's still a big deal to undergo and recover from."

The study was supported by the National Center for Advancing Translational Sciences, part of the National Institutes of Health. The authors and Dr. Bhargava have disclosed no relevant financial relationships..

Clin Gastroenterol Hepatol. 2013;11:1424-1429. Abstract

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