1232P CROSS protocol for esophageal cancer in India: Reality or pipe dream?

Abstract

CROSS(Chemoradiotherapy for Oesophageal cancer followed by surgery study) published in 2012 proved to be a practice changing study for treatment of locally advanced esophageal cancer located at the middle and lower third of esophagus. When chemoradiotherapy followed by surgery became the standard of care for the treatment of locally advanced esophageal cancer, we, at the tertiary care centers of India struggled to bring this concept home because of various obstacles in low middle income countries like ours. Limited infrastructure, overpopulation, financial issues, ignorance and the lack of a strong multidisciplinary team are the various stumbling blocks. Most ardous task is to convince patients to go for surgery of the so called food pipe, specially after symptomatic relief by the neoadjuvant chemoradiation treatment. Retrospective study done in Department of Radiotherapy, at tertiary centre in Northern India. All histopathology proven cases of carcinoma esophagus registered in our department from january 2019 to December 2021, eligible for the CROSS protocol were taken for this study. Total 246 patients of carcinoma esophagus were registered in our department from January 2019 to December 2021 of which 85 were non metastatic, locally advanced disease involving the middle or lower third of esophagus and were eligible for the CROSS protocol. 47(55.3%) patients denied any form of surgical intervention at the begining of the treatment and were given definitive chemoradiation. 29(34%) refused surgery after neoadjuvant treatment, only 9(10%) patients completed the whole treatment. We found that out of all the patients eligible for surgery only 10% could complete the whole treatment including chemoradiotherapy and surgery. CROSS trial established a benchmark in treatment of esophageal cancer, but real-world data of tertiary care centre in India shows that providing optimal treatment to patients of esophageal cancer is still a tough row to hoe because of reasons extending from unwillingness to undergo major surgery to economic crisis and lack of MDT in several centres. Better and acceptable treatment protocols with organ preservation needs to be studied and adopted in low middle income countries which have high burden and low infrastructure.