For patients with locally advanced oesophageal adenocarcinoma that can be treated with surgery, chemotherapy treatment before and after surgery improved survival when compared to chemoradiotherapy before surgery.

The research was presented at the 2024 American Society of Clinical Oncology (ASCO) Annual Meeting, taking place May 31-June 4 in Chicago, Illinois.

The phase 3 ESOPEC clinical trial compared two treatment strategies for locally advanced oesophageal adenocarcinoma that could be treated with surgery. The CROSS protocol is treatment with chemoradiotherapy before surgery.

The FLOT protocol is treatment with chemotherapy before and after surgery. A total of 221 participants were randomised to the FLOT protocol arm and 217 participants were randomised to the CROSS protocol arm.

The median age of the study participants was 63 years, and 89% of the participants were men.

About 70% of oesophageal cancer diagnoses are in men.

Key Findings

For all study participants, 403 started some form of treatment and 371 went on to receive surgery (191 in the FLOT arm and 180 in the CROSS arm). 

In the 90 days after surgery, 4.3% of the participants had died (3.2% in the FLOT arm and 5.6% in the CROSS arm), and after a median follow-up of 55 months, 218 participants had died (97 in the FLOT arm and 121 in the CROSS arm). 

Median overall survival was 66 months (5 years, 6 months) in the FLOT arm and 37 months (3 years, 1 month) in the CROSS arm.

At 3 years, participants who received FLOT had a 30% lower risk of dying than those who received CROSS. The 3-year overall survival rates were 57% for the FLOT arm and 51% in the CROSS arm.

Of the 359 participants whose tumour regression status was known, a pathological complete response was achieved in 35 patients in the FLOT arm and 24 in the CROSS arm. 

“Many patients in the U.S. and Europe are still treated with the CROSS radiochemotherapy protocol. Our study shows that patients with resectable oesophageal cancer should have FLOT chemotherapy before and after the operation in order to optimise the chance of curing their tumours in the long term,” said lead study author Jens Hoeppner, MD, FACS, FEBS, University Medical Center OWL, University of Bielefeld, Detmold, Germany

“There is considerable disagreement as to whether giving all adjuvant therapy upfront versus ‘sandwich’ adjuvant therapy before and after surgery is the better standard of care for locally advanced resectable oesophageal cancer. This randomised clinical trial from Europe answers that question for patients similar to those in enroled in the trial: preoperative plus postoperative chemotherapy provides better outcomes.” – Jennifer Tseng, MD, MPH, Boston Medical Center, Boston, Massachusetts

Next Steps

Researchers will study whether surgery can be avoided in patients with cancers that have a complete pathological response to treatment with the FLOT or CROSS protocols and show no growth during active surveillance.

Active surveillance is when regular tests, such as blood tests and radiologic imaging, are done to monitor if a cancer has come back.

When surgery is avoided, the oesophagus is preserved, giving patients a better quality of life. 

Source: ASCO