Surgery is the mainstay of esophageal cancer treatment. However, in the case of progressive esophageal cancer, a combination of chemotherapy or radiotherapy before or after surgery can improve survival rates. Treatment given before surgery is then referred to as neoadjuvant therapy, while that given after surgery is referred to as adjuvant therapy.
In this article, we focus on the issues related to neoadjuvant therapy.
Why neoadjuvant therapy?
Neoadjuvant therapy is like a “head start” to reduce the risk of distant metastases after surgery by giving the tumor a head start before surgery to shrink the lesion, reduce microscopic metastases, and achieve a reduced tumor stage. The ultimate goal is to improve the therapeutic effect of surgery and to increase long-term survival rates.
Specifically:
1. further shrinking of the tumor with neoadjuvant therapy may improve the postoperative complete resection (R0, i.e., no tumor remaining microscopically after resection) rate;
2. Removal of tiny metastases or invisible tumor cells in the body, reducing the risk of tumor recurrence after surgery;
3. Preliminary determination of tumor sensitivity and malignancy to chemotherapy drugs through efficacy assessment of neoadjuvant therapy for subsequent treatment.
Do I need to do it?
It is worth clarifying that not all patients with esophageal cancer have to receive neoadjuvant therapy.
Neoadjuvant therapy is primarily indicated for patients with locally progressive esophageal cancer.
Clinical studies have shown that some patients with surgically resectable locally advanced disease may be considered for neoadjuvant therapy to improve surgical resection rates, reduce the risk of recurrence, and prolong overall survival without increasing the incidence of postoperative complications.
To put it directly, early-stage esophageal cancer can be cured directly by surgery, which includes endoscopic mucosal resection and open surgery in the traditional sense (including thoracoscopic surgery), and neoadjuvant therapy is not required. Because early-stage patients do not have lymph node metastasis, cancer cells have not metastasized to other organs, and the extent of tumor invasion of esophageal tissue is relatively small.
If surgical resection is lost at the time of diagnosis, refer directly to the treatment of advanced esophageal cancer.
Advanced patients are treated with a combination of chemotherapy-based therapy, often in conjunction with local palliative radiotherapy, interventional therapy, and treatment of related complications.
There is a special case where a patient has been judged to be unresectable for surgery, but after chemotherapy, the lesion is found to be significantly smaller and meets the indications for surgery. This “step-by-step” model of chemotherapy is called “translational therapy” and is not the same as neoadjuvant therapy, which is very purposeful from the start.
To learn more about advanced esophageal cancer treatment, read about it:
So why do some people have radiotherapy before surgery (neoadjuvant therapy), while others have surgery first and then radiotherapy (adjuvant therapy)?
This is because the staging that your doctor does before surgery is called “clinical staging”. After surgery to remove the cancer, the specimen is sent to pathology for biopsy, and the pathology report, which comes out about 1 week later, is called “pathologic staging.
Pathologic staging is closer to the actual tumor and is known as the “gold standard” for diagnosis.
If you have an early clinical stage, but then you have a progressive stage based on the pathologic stage after surgery, it’s time for adjuvant radiotherapy.
Co-written by Dr. Jing You Dr. Chang Liu
, Peking University Cancer Hospital