COMMENTARY

More Intense Neoadjuvant ECX Chemotherapy Regimen Fails for Esophageal Cancer

David J. Kerr, CBE, MD, DSc, FRCP, FMedSci

Disclosures

January 25, 2018

Hello. I am David Kerr, professor of cancer medicine at University of Oxford in England. Today I want to discuss a trial led by Derek Alderson and David Cunningham and reported very recently in Lancet Oncology.[1] This trial looked at the potential benefits of neoadjuvant chemotherapy in patients with operable adenocarcinoma of the esophagus.

We know that two cycles of cisplatin and fluorouracil (5-FU) improve survival in the neoadjuvant setting, and this trial set out to explore whether intensifying the chemotherapy would provide better survival benefits. It was a large, well-designed trial, comprising patients from 72 centers in the United Kingdom. Approximately 900 patients with well-defined, operable adenocarcinoma of the esophagus at the gastroesophageal junction were randomly assigned to receive conventional chemotherapy (two cycles of cisplatin 5-FU) or the experimental arm with four cycles of epirubicin, cisplatin, and capecitabine (ECX) before resection. ECX is a regimen developed by David Cunningham and colleagues in the earlier MAGIC trials.[2] This was a well-designed trial with well-controlled surgeries at high-quality centers, so we are pretty certain of the quality of both the delivered chemotherapy and the surgeries.

All the more disappointing, then, that the trial showed no evidence of any survival benefits for the more intense ECX chemotherapy. The median survival was around 24 months for both arms of the trial, with no clinically or statistically significant difference separating the two chemotherapy regimens. Not surprising, the more intensive chemotherapy was a bit more toxic, with a few more adverse effects, but not markedly so.

The search continues. Esophageal cancer is a difficult disease to manage, and even in patients with operable disease, it has a median survival of only around 2 years. Thus, we need better drugs, better approaches, better ideas. Although it was logical to attempt this, ECX is not the answer.

As always, thanks for listening. I would be very interested in your comments and ideas about this important, well-designed, large trial with a rather disappointing result. For the time being, Medscapers, over and out.

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