Esophagus Carcinoma Surveillance Counterpoint: Australia

Abstract

The demographics of esophageal cancer in Australia reflect those of other Western countries [1] with a rising incidence in adenocarcinoma of the lower esophagus and esophago-gastric junction. However, in Western countries we still see patients with squamous cell carcinoma of the thoracic and cervical esophagus. The other change over the last 20 years has been an evolution of the use of the combination of chemotherapy with radiation therapy in the management of patients with esophageal cancer. Traditionally, resection was the definitive curative therapy, with radiation therapy used for patients who were not medically fit or who refused resection. However, the combination of chemoradiation therapy without resection was shown to offer a greater potential for cure for patients with squamous cell carcinoma, when compared with radiation therapy alone [2]. Thus, the recent trend has been to use concurrent chemoradiation therapy as definitive treatment or as neoadjuvant therapy for those patients having a resection [3, 4]. Recently, two randomized studies have supported the use of definitive chemoradiation therapy instead of esophageal resection in medically fit patients with squamous cell carcinoma [5, 6]. The role for definitive chemoradiation therapy in patients with adenocarcinoma of the esophagus is not clear, as most trials have had a predominance of squamous cell carcinoma. At this time the gold standard is still resection for locally advanced disease with the use of preoperative chemotherapy or chemoradiation therapy, given the survival benefits shown in meta-analyses [7]. There are some data to suggest that neoadjuvant chemoradiation therapy results in downstaging and improves resectability [8, 9].