An updated meta-analysis provides strong evidence for a survival benefit of neoadjuvant chemoradiotherapy and chemotherapy over surgery alone in patients with oesophageal carcinoma.

The overall survival of patients with resectable oesophageal cancer remains poor, with a five-year survival of 15 to 34 %. Due to the difficulties in administering chemotherapy or radiotherapy soon after a surgical procedure, the focus of recent trials has been on delivering neoadjuvant treatment.

In a previous meta-analysis Val Gebski and colleagues from the National Health and Medical Research Council Clinical Trials Centre,Camperdown, Australia, reported a significant survival benefit for neoadjuvant chemoradiotherapy and to a lesser extent neoadjuvant chemotherapy in patients with squamous-cell carcinoma or adenocarcinoma of the oesophagus.

Since publication of this research treatment modifications have included use of more modern cytotoxic drugs, changes in chemotherapy sequencing and changes in the dose and fractionation of radiotherapy.

In the current analysis Gebski and colleagues update the meta-analysis adding seven new studies published since January 2006 to the original 17 trials. The updated meta-analysis contained 4188 patients compared to 2933 in the earlier publications and 3500 events compared with 2230 in the previous analysis.

Results show that the HR for all cause mortality for neoadjuvant chemoradiotherapy was 0.78 (p<0.0001); while the HR for all-cause mortality for neoadjuvant neoadjuvant chemotherapy was 0.87 (p=0.01). The HR for the overall indirect comparison of all-cause mortality for neoadjuvant chemoradiotherapy versus neoadjuvant chemotherapy was 0.88 (p=0.07).

"The additional information has strengthened the evidence of a survival advantage of neoadjuvant therapy compared with surgery alone," write the authors, adding that although the benefit for neoadjuvant chemotherapy was not as great as for neoadjuvant chemoradiotherapy a clear advantage has not been established. "Further randomised trials comparing these two strategies are warranted," they conclude.

From the study it was impossible to establish the optimum neoadjuvant treatment regimen since the trials used different drugs, doses and schedules of chemotherapy and radiotherapy.

KM Sjoquist, B H Burmeister, B M Smithers et al. Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-analysis. Lancet Oncol 2011; DOI: 12:681-92.