The management of dysphagia in esophageal adenocarcinoma patients undergoing neoadjuvant chemotherapy: Can invasive tube feeding be avoided?

Abstract

e15034 Background: Neoadjuvant chemotherapy is an accepted standard for locally advanced esophago-gastric adenocarcinoma. However the dysphagia frequently associated with this condition may interfere with patient tolerance of neoadjuvant chemotherapy. Surgical or endoscopic invasive tube feeding (ITF), including stents, is a commonly employed strategy to maintain nutritional support however it can cause significant morbidity in its own right. We sought to determine if an approach of careful dietary counseling and fast-tracked neoadjuvant chemotherapy can obviate the need for ITF. Methods: Pts undergoing neoadjuvant chemotherapy (DCF or ECF Q3 weeks x3 or FLOT Q2weeks x4) for locally advanced (cT3 and/or N+) esophageal or EGJ adenocarcinoma at a single institution from 3/07-9/12 were identified from a prospective database. All received dietary counseling and were closely monitored for signs/ symptoms of malnutrition with serial (baseline/pre-surgery) Body Mass Index (BMI), albumin, dysphagia scores (DS: 0 best - 4 worse), and quality of life (FACT-E). We assessed the response of dysphagia and nutritional status to neoadjuvant treatment and the need for ITF. Data presented as median (Interquartile Range) or median (±SD), paired t-test or Wilcoxon signed ranks test determined significance (*p=0.05). Results: Of 130 patients undergoing neoadjuvant chemotherapy 78 had dysphagia scores of 2 or greater, most of whom received DCF (91%). Overall the dysphagia improved in 75/78 (96%) from a DS of 3 (2-4) to 0 (0-1)*. This was associated with an increase in FACT-E QoL scores (117±23 to 140±20)*. Weight (Kg)(70±22:69±24), BMI (24.5±8 to 23.9±7), and Albumin (40±5 to 37±4) were maintained. Only one patient required a stent, and none a jejunostomy, or gastrostomy. Conclusions: Appropriately timed neoadjuvant chemotherapy with a highly effective regimen rapidly restores normal swallowing, maintains nutritional status, and obviates the need for stenting or invasive tube feeding in patients with significant dysphagia from esophageal adenocarcinoma.