The current status of esophageal cancer treatment in North America

Abstract

Cancer of the esophagus and gastroesophageal junction (GEJ) in North America remains a relatively small but challenging clinical problem. It is estimated that, in 2004, 21 000 new esophageal cancers will be diagnosed (of which more than 75% will be in men) and 19 600 deaths from esophageal cancer will occur. In contrast to the Asian experience, adenocarcinomas of the esophagus and GEJ comprise more than half of all esophageal malignancies. Other than surveillance endoscopy in patients with Barrett’s esophagus, there are currently no useful screening techniques for esophageal cancer. The lack of an early detection algorithm determines the distribution of stage at the time of diagnosis: stages 0, I 16%; IIA, IIB 26%; III 26%; IV 32%. Standard staging algorithms currently include computed tomography and sometimes a contrast esophagram. Fewer than 20% of patients undergo endoscopic ultrasonography (EUS), and an even lower incidence of positron emission tomography (PET) scanning is evident. Although data for the utility of neoadjuvant therapy before surgery for esophageal cancer are lacking, as many as 50% of resectable patients undergo such therapy. The choice of the method of resection has not changed for more than a decade, with only one-fourth of operations being performed using a transhiatal technique. Current surgical controversies include the extent of en bloc resection, the extent of nodal dissection, the utility of minimally invasive esophagectomy techniques, and hospital and surgeon case volume as a surrogate for quality outcomes. Unlike Asia and Europe, the free market philosophy of medical care in North America leads to widespread distribution and subsequent dilution of cancer care experience. However, it is likely that market forces will begin to encourage the development of centers of excellence for surgical therapy of esophageal cancer. There is a growing interest in treating localized cancers with chemoradiotherapy alone, and the use of EUS and PET for restaging these patients is being investigated. Some investigators believe that esophagectomy may soon be relegated to the role of a salvage operation. New biological agents are currently being evaluated as part of multimodality therapy for esophageal cancer, including radiation-induced release of TNF-alpha, statins, immunotoxins, and epithelial growth factor receptor (EGFR) tyrosine kinase inhibitors. Current free market forces may slow progress in standard cancer care but perhaps will provide opportunities for new and unique treatment methods that otherwise may not be explored in more traditional centers of excellence.