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2499
The Evaluation and Treatment of Patients Receiving
Radiation Therapy for Carcinoma of the Esophagus
Results of the 1992–1994 Patterns of Care Study
Lawrence R. Coia, M.D.1
Bruce D. Minsky, M.D.2
Madhu J. John, M.D.3
Daniel G. Haller, M.D.4
Jerome Landry, M.D.5
Thomas M. Pisansky, M.D.6
Christopher G. Willett, M.D.7
John P. Hoffman, M.D.8
Brian A. Berkey, M.S.9
Jean B. Owen, Ph.D.9
Gerald E. Hanks, M.D.8
BACKGROUND. For the first time, a Patterns of Care Study (PCS) was conducted in
1992–1994 to determine the national practice standards in evaluating and treating
patients with esophageal carcinoma and to determine the degree to which clinical
trials have been incorporated into national practice.
METHODS. A national survey of 61 institutions using 2-stage cluster sampling
was conducted, and specific information was collected on 400 patients with
squamous cell carcinoma or adenocarcinoma of the thoracic esophagus who
received radiation therapy (RT) as part of definitive or adjuvant management of
their disease. Patients were staged according to a modified 1983 American Joint
Committee on Cancer staging system. Chi-square tests for significant differences between academic and nonacademic institutions for a particular variable
were performed.
1
Community Medical Center, Toms River, New
Jersey.
2
RESULTS. The median age of patients was 66.7 years (range, 26 – 89 years); 76.5%
were male and 23.5% were female. Karnofsky performance status was $80 for
Memorial Sloan-Kettering Cancer Center, New
York, New York.
88.3% of patients. Squamous cell carcinoma was diagnosed in 61.5% and adeno-
3
29.5% CS III. Evaluative procedures included endoscopy (.93%), computed to-
Cancer Center at St. Agnes, Fresno, California.
4
University of Pennsylvania Medical Center, Philadelphia, Pennsylvania.
5
Emory University, Atlanta, Georgia.
6
carcinoma in 36.8%. Fifteen percent were Clinical Stage (CS) I, 39.5% CS II, and
mography (CT) of the chest (86%), CT of the abdomen (75%), esophagography
(68.5%), and endoscopic ultrasound (3.5%). Endoscopic ultrasound and CT of the
chest were performed significantly more frequently at academic than nonacademic
facilities (6.1% vs. 1.0% and 91.9% vs. 81.3%, respectively). Three-quarters of all
Mayo Clinic and Mayo Foundation, Rochester,
Minnesota.
patients received chemotherapy and RT and 62.5% received concurrent chemo-
7
RT (54.0%), RT alone (20.3%), preoperative chemotherapy 1 RT (13.3%), postop-
Cox Cancer Center, Boston, Massachusetts.
8
American College of Radiology, Philadelphia,
Pennsylvania.
9
Fox Chase Cancer Center, Philadelphia, Pennsylvania.
Presented at the 80th Annual Meeting of the American Radium Society, Monte Carlo, Monaco, May
2– 6, 1998.
Supported by Grant No. CA94006 from the National Cancer Institute, National Institutes of
Health.
The authors thank Angela Katz, M.D., and Irene
Mahon, R.N., M.P.H., for their technical assistance
in data collection.
therapy and RT as part of their treatment. Treatments included chemotherapy plus
erative chemotherapy 1 RT (7.7%), postoperative RT (3.5%), and preoperative RT
(1.2%). The chemotherapeutic agents most frequently used were 5-fluorouracil
(84%), cisplatin (64%), and mitomycin (9%); academic instututions used cisplatin
significantly more often and mitomycin significantly less often than nonacademic
institutions. Brachytherapy was used in 8.5% of cases. The median total dose of
external beam radiation was 50.4 gray and the median dose per fraction was 1.8
gray.
CONCLUSIONS. This study establishes the national benchmarks for the evaluation
and treatment of patients with esophageal carcinoma at radiation facilities in the
U.S. It also indicates that the majority of patients given RT as a component of
treatment for esophageal carcinoma receive chemoradiation rather than RT alone,
as supported by clinical trials. Although some differences in the evaluation of
esophageal carcinoma were noted between academic and nonacademic facilities,
there was no difference in the frequency of use of chemoradiation versus RT by
Address for reprints: Lawrence R. Coia, M.D., Department of Radiation Oncology, Community Medical
Center, 99 Highway 37 West, Toms River, NJ 08755.
facility type. Cancer 1999;85:2499 –505. © 1999 American Cancer Society.
Received October 30, 1998; revision received
March 1, 1999; accepted March 1, 1999.
KEYWORDS: esophageal carcinoma, Patterns of Care Study, preoperative chemoradiation, chemoradiation alone.
© 1999 American Cancer Society
2500
T
CANCER June 15, 1999 / Volume 85 / Number 12
he Patterns of Care Study (PCS) periodically establishes national benchmarks for malignancies in
which radiation therapy plays an important role. PCS
is funded by grants and contracts from the National
Cancer Institute (NCI) and administered by the American College of Radiology (ACR). PCS was begun in
1971 in an effort to improve the quality of and accessibility to radiation oncology throughout the U.S. Its
operating premise was that differences in practice patterns exist, these difference can be measured, and
deficiencies can be corrected. Major disease sites that
PCS has periodically studied have included carcinomas of the uterine cervix, breast, prostate, and rectum,
Hodgkin disease, and seminoma, among others.1 For
the first time, PCS decided to study national practice
patterns in the use of radiation to treat carcinoma of
the esophagus, and the results are presented herein.
Esophageal carcinoma is responsible for approximately 12,000 deaths annually in the U.S. Compared
with rectal carcinoma, which occurs four times as
frequently, there are more deaths annually from
esophageal carcinoma.2 Radiation has been used in
the treatment of esophageal carcinoma alone, preoperatively, or postoperatively. More recently, however,
radiation has been combined with chemotherapy either as an adjuvant to surgery or as primary treatment.
Because of the importance of esophageal carcinoma
in the U.S. and the increasing role of radiation in its
treatment, esophageal carcinoma was felt to be an
appropriate disease for study by PCS.
Along with the increased use of multimodal treatment for esophageal carcinoma there has been a
change in the predominant histology. The incidence
of adenocarcinoma of the esophagus has increased at
a rate greater than that of nearly any other cancer over
the past 2 decades.3 Although previously the ratio of
squamous cell carcinoma of the esophagus to adenocarcinoma was approximately 9 to 1, the incidence
rates of these histologies are currently approximately
equal.4 Whether patients with adenocarcinoma of the
esophagus should be treated similarly to patients with
squamous cell carcinoma and whether the outcome of
treatment varies according to histology are issues of
interest to the practicing radiation oncologist.
The potential benefits of concurrent chemotherapy and radiation (CRT) over radiation alone for
esophageal carcinoma were suggested in several
Phase II trials in the latter part of the 1980s.5–7 In 1992,
Herskovic et al. published the results of a Phase III
Intergroup clinical trial that demonstrated the superiority of CRT over radiation alone.8 Since the publication of those trial results, CRT has been considered
one of the standard treatments for esophageal carcinoma.
The objectives of this study were to determine the
national practice standards for the evaluation and
treatment of esophageal carcinoma with radiation.
Furthermore, because significant improvement in the
outcomes of patients treated with CRT over radiation
alone had been demonstrated, this study sought to
examine the penetrance of such clinical trial results
into national practice. Specifically, this study selected
and examined the records of patients with esophageal
carcinoma treated with radiation between 1992 and
1994, when the results of the Intergroup became
widely distributed.
METHODS
A national sample of 61 radiation facilities was selected from a master list of all facilities in the U.S. in
1992. A stratified two-stage cluster sample was used to
select facilities and patients for review. In the first
stage of sampling, facilities were selected. Nineteen
academic and 42 nonacademic facilities were chosen.
For the purposes of this study, academic facilities were
defined as NCI-designated comprehensive cancer
centers or the main teaching hospital of a medical
school. All others were considered nonacademic. In
the second stage, a randomized selection of records of
patients from each facility treated with radiation for
esophageal carcinoma was carried out.
Data were collected between 1995 and 1997 by a
PCS research associate who traveled to each facility
and reviewed the records on site. All radiation therapy
records were reviewed. In addition, hospital records
were requested but not always available for review.
The PCS Consensus Committee that dealt with esophageal carcinoma developed the survey forms used to
collect the information. That committee had previously convened to discuss guidelines for the management of esophageal carcinoma and determined key
areas of interest in the evaluation and management of
the disease for this nationwide study. The results of
their management guidelines have been published.9
To be eligible for this study, patients had to meet
several criteria. First, patients were required to have
been treated with radiation for esophageal carcinoma
between 1992 and 1994. The decision was made to
study patients with either squamous cell carcinoma or
adenocarcinoma of the esophagus, including the thoracic esophagus and the gastroesophageal (GE) junction. Those with GE junction cancers were not studied
if there was gastric extension. Patients with 1983
American Joint Commission on Cancer (AJCC) Stage I,
II, or III esophageal carcinoma who had no evidence
of distant metastasis were eligible for review. It should
be noted that the staging system was a modification of
the 1983 AJCC staging system, as shown in Table 1.
Radiation for Esophageal Carcinoma/Coia et al.
2501
TABLE 1
Comparison between the 1983 and 1997 AJCC TNM Classification and Stage Groupings for Esophageal
Carcinomaa
Modified 1983 classification
1997 classification
Primary Tumor (T) clinical classification
Tis Carcinoma in situ
T1 Tumor involves 5 cm or less of esophageal length, produces no obstruction,
and has no circumferential involvement
T2 Tumor involves more than 5 cm of esophageal length, causes obstruction, or
involves the circumference of the esophagus
T3 Extraesophageal spreadb
T4
Lymph node involvement (N) pathologic classification
N0 No positive lymph nodes (surgical evaluation)
N1 Positive lymph nodes (surgical evaluation)
NX Regional lymph nodes for the upper, midthoracic esophagus that are not
ordinarily accessible for clinical evaluation (clinical evaluation)
Distant metastasis (M) clinical classification
M0 No distant metastasis
M1 Distant metastasis
Stage grouping
Stage I T1, N0 or NX, M0
Stage II T2, N0 or NX, M0
Stage IIA
Stage IIB
Stage III T3, any N, M0
Stage IV Any T, any N, M1
Noninvasive
Tumor invades lamina propria or submucosa
Tumor invades muscularis propria
Tumor invades adventitia
Tumor invades adjacent structures
No regional lymph node metastasis
Regional lymph node metastasis
No distant metastasis
Distant metastasisc
T1, N0, M0
T2–T3, N0, M0
T1–T2, N1, M0
T3, N1, M0 or T4, any N, M0
Any T, any N, M1
AJCC: American Joint Committee on Cancer; CT: computed tomography.
a
Data from 1983 and 1997 editions of the AJCC Manual for Staging of Cancer.
b
Extraesophageal spread is defined by recurrent laryngeal nerve involvement, positive pleural effusion, tracheoesophageal fistula, sympathetic nerve involvement,
phrenic nerve involvement, or widened mediastinum on chest radiograph. In this modified staging system, CT scan evidence of local extraesophageal extension was
allowed to indicate T3.
c
Distant metastases include cervical or celiac lymph node involvement for tumors of the thoracic esophagus.
The 1983 AJCC staging system was used because it was
a clinically based system that did not require the use
of an initial surgical resection to determine stage. The
1997 AJCC system is also shown in Table 1 for comparison. Additional eligibility requirements were that
patients had to have a Karnofsky performance status
greater than 50 and could not have had another type
of malignancy within the 5 years prior to treatment.
National averages from sampling were developed
by Sedransk et al.,10 and methodology for PCS development of national averages have recently been reviewed by Owen et al.11 Tests for significant differences between parameters under study were
determined by the chi-square test. Consistency checks
were performed on all tabulations.
RESULTS
Four hundred patients whose records were reviewed
met the eligibility criteria for this study. One hundred
ninety-seven were from academic facilities and 203
were from nonacademic facilities. Patient and tumor
characteristics are shown in Table 2. The median age
was 66.7 years. More than three-quarters of the patients were male. Eighty-eight percent had a Karnofsky
performance status greater than or equal to 80. Sixtytwo percent of the patients had squamous cell carcinoma, and only 15% had clinical Stage I malignancies.
Methods of tumor evaluation are shown in Table
3. Over two-thirds of patients had an esophagogram
and nearly all had an endoscopy. Endoscopy was not
performed for 6% of patients, probably due to lack of
documentation, because all patients had histologic
proof of malignancy.) On the other hand, endoscopic
ultrasound was performed for only 3.5% of patients.
There was a significant difference in the rates of performance of endoscopic ultrasound at academic and
nonacademic institutions (6% vs. 1%). In addition,
there was a significantly higher rate of computed tomography (CT) scanning of the chest at academic and
nonacademic institutions (92% vs. 80%).
Table 4 lists the major treatments given. Threequarters of the patients received chemotherapy and
radiation therapy alone (54%), preoperatively (13.25%),
or postoperatively (7.75%). One-quarter of patients
2502
CANCER June 15, 1999 / Volume 85 / Number 12
TABLE 2
Patient and Tumor Characteristics of 400 Patients with
Esophageal Carcinoma
Characteristic
No. of patients
Total no.
Age (yrs)
Range
Median
Gender
Male
Female
KPS
#70
80
90
100
Unknown
Histology
Squamous
Adenocarcinoma
Unknown
Clinical stage
I
II
III
Unknown
Race
White
Hispanic
African American
Asian
Native American
Unknown
400
TABLE 3
Percentage of Patients Undergoing Specified Evaluative Procedures
Total
A
Non-A
69%
94%
3.5%
86%
75%
69%
94%
6%
92%
80%
68%
93%
1%
80%
70%
(%)
Esophagogram
Endoscopy
Endoscopic USa
CT scan, chestb
CT scan, abdomen
26–89
66.7
306
94
(76.5%)
(23.5%)
38
165
176
12
9
(9.5%)
(41.3%)
(44%)
(3%)
(2.3%)
246
147
7
(61.5%)
(36.8%)
(1.8%)
60
158
118
64
(15%)
(39.5%)
(29.5%)
(16%)
290
8
81
14
1
1
(73.8%)
(2%)
(20.3%)
(3.5%)
(0.3%)
(0.3%)
KPS: Karnofsky performance status.
received radiation alone (20.25%), preoperatively
(1.25%), or postoperatively (3.5%). Chemotherapy and
radiation alone was the most frequently used regimen
for both squamous cell and adenocarcinoma and for
all stages. Trimodality treatment was more frequently
used for patients with adenocarcinoma than for those
with squamous cell carcinoma (34% vs. 14%). Only 29
patients (7%) were treated on an investigational protocol, including 15 on Institutional Review Board–approved institutional trials and 5 on NCI-sponsored
group trials.
Further information on chemotherapy administration is shown in Table 5. A significant difference in
the rate of administration of chemotherapy between
academic and nonacademic institutions was not apparent. Sixty-three percent of patients received 5-fluorouracil, 48% received cisplatin, and 6.8% received
mitomycin. Academic institutions used cisplatin more
frequently than nonacademic institutions (57% vs.
40%, P 5 0.001); however, nonacademic institutions
A: academic; non-A: nonacademic; US: ultrasound; CT: computed tomography.
a
P 5 0.02 (A vs. Non-A).
b
P 5 0.002 (A vs. Non-A).
used mitomycin more frequently (11% vs. 3%, P 5
0.001).
CRT was given to 63% of patients, as detailed in
Table 6. Academic institutions administered CRT significantly more often than nonacademic (67% vs. 58%,
P 5 0.046). However, the rate at which CRT alone
(without surgery) was given did not differ significantly
between academic and nonacademic institutions
(46% vs. 45%). Overall, preoperative CRT was given to
12% of patients, whereas postoperative CRT was given
to 5%. Academic institutions used preoperative CRT
more frequently than nonacademic institutions (18%
vs. 7%), whereas postoperative CRT was used infrequently at both academic and nonacademic centers
(3% vs. 6%). The most frequent dose range used was
$50 gray (Gy) for those who received CRT alone as
well as for the postoperative CRT group, whereas the
most frequent dose range for the preoperative CRT
group was 40 Gy to ,50 Gy.
The parameters of radiation therapy are listed in
Table 7. Eighty-three percent of patients were treated
in a supine position. The median dose per fraction was
1.8 Gy and the median total dose was 50.4 Gy. The
most frequent dose-per-fraction range was 1.9 –2.0 Gy,
whereas the most frequent total dose range was 50 Gy
to ,60 Gy. The median overall treatment duration was
40.5 days. Brachytherapy was given to 34 patients
(8.5%); nearly all patients received brachytherapy in
combination with external beam. High-dose-rate
brachytherapy (HDR) was given more frequently than
low-dose-rate brachytherapy (7.3% vs. 1.2%). Furthermore, nonacademic institutions used HDR brachytherapy more frequently than academic institutions
(5.5% vs. 1.75%, P 5 0.002). The median HDR dose was
10 Gy and the median number of applications was 2.
CONCLUSIONS
This study establishes the national benchmarks for the
evaluation and treatment of esophageal carcinoma at
radiation facilities in the U.S. As it is based on infor-
Radiation for Esophageal Carcinoma/Coia et al.
2503
TABLE 4
Treatments Used in the Study Overall and by Stage and Histology
No. of patients
Chemo and RT (total)
Alone
With surgery
Pre-op
Post-op
RT (total)
Alone
With surgery
Pre-op
Post-op
%
Overall
Squamous
Adeno
Stage I
Stage II
Stage III
75.0%
54.0%
21.0%
13.25%
7.75%
25.0%
20.25%
4.75%
1.25%
3.5%
300
216
84
53
31
100
81
19
5
14
176
142
34
25
9
70
59
11
3
8
120
70
50
28
22
27
19
8
2
6
44
33
11
10
1
16
13
3
0
3
126
88
38
28
10
32
30
2
1
1
93
67
26
11
15
25
18
7
2
5
RT: radiotherapy; Adeno: adenocarcinoma.
TABLE 5
Frequency and Type of Chemotherapy Usage
TABLE 6
Timing of Concurrent Chemotherapy and Radiation Therapy and
Dose Ranges of Radiation Used
% of patients
Total
Chemotherapy given
Agents used
5-FU
Cisplatina
Mitomycina
A
Total
A
Non-A
63%
46%
4%
9%
33%
12%
3%
5.5%
3.8%
5%
0.3%
2%
3%
67%
46%
58%
45%
18%
7%
3%
6%
Non-A
75%
76%
74%
63%
48%
6.8%
65%
57%
3%
62%
40%
11%
A: academic; Non-A: nonacademic; 5-FU: 5-fluorouracil.
a
P 5 0.001.
mation available from radiation therapy charts and
hospital charts, it may occasionally underestimate
procedure performance. Nonetheless, the study indicates that such evaluation and treatment are similar at
academic and nonacademic facilities. It also suggests
early penetrance of clinical trial results into national
practice, as CRT was used more frequently than radiation alone.
Regarding pretherapy evaluation, this study indicates that endoscopic ultrasound was infrequently
used. The current AJCC T classification is based on the
depth of esophageal wall penetration by the tumor.
Only an initial surgical resection (i.e., esophagectomy)
or endoscopic ultrasound can determine this depth.
Patients not undergoing surgery cannot be completely
staged according to the 1997 AJCC system without the
use of endoscopic ultrasound. Because endoscopic
ultrasound is infrequently used, and because the
depth of wall penetration has not been shown to be of
prognostic importance in the management of patients
with initial chemoradiation, a modification of the current AJCC staging system to take into account readily
Concurrent chemo and XRTa
No surgery
,40 Gy
40–,50 Gy
$50 Gy
Pre-op
,40 Gy
40–,50 Gy
$50 Gy
Post-op
,40 Gy
40–,50 Gy
$50 Gy
A: academic; Non-A: nonacademic; XRT: radiation therapy; Gy: gray.
a
P 5 0.046.
available and prognostically important tumor measures, such as length and degree of circumferential
involvement, seems justified. Esophagography, which
remains an important indicator of tumor length and
location for the radiation oncologist, was used to evaluate over two-thirds of the patients. The less frequent
use of esophagography than of CT of the thorax may
reflect the increased reliance of the radiation oncologist on the CT scan for tumor localization. It should be
also noted that the CT scan has been demonstrated to
be less accurate in determining tumor length than
esophagography or esophagoscopy; however, simulation is successful for most patients with the aid of a
barium swallow.12 While not a diagnostic substitute
for esophagography, the use of barium at simulation
2504
CANCER June 15, 1999 / Volume 85 / Number 12
TABLE 7
Radiation Parameters
Parameters
RT given
External beam only
Brachytherapy only
Both
Machine energy
6 MV
10 MV
18 MV
Other
Unknown
Patient position
Supine
Prone
Both
Unknown
Total dose
Range
#30 Gy
.30–,40 Gy
40–,50 Gy
50–,60 Gy
$60 Gy
Total dose
Median
Dose/FX
Range
#1.8 Gy
1.9–2.0 Gy
.2.0 Gy–,3.0 Gy
$3.0 Gy
Median
Treatment duration
Median
Brachytherapy
Overalla
HDRa
Median dose
(Range)
Median no. of applications
(Range)
LDR
TABLE 8
Comparison of Treatments Delivered in the PCS and ACS Studies
No. of patients
(%)
366
3
31
(91.5%)
(0.8%)
(7.8%)
139
87
79
88
4
(35.0%)
(22.0%)
(20.0%)
(22.0%)
(1.0%)
330
38
8
21
(83.0%)
(10.0%)
(2.0%)
(5.0%)
Treatment
ACS (%)
ACS(M) (%)
PCS (%)
Surgery alone
RT alone
CT alone
SX 1 RT
SX 1 CT
RT 1 CT
All three
No Rx
Unknown
18
13
7
4
3
30
9
14
3
—
23
—
7.5
—
55
16
—
—
—
20
—
5
—
54
21
—
—
ACS: American Cancer Society; ACS(M): ACS data limited to those receiving radiation; PCS: Patterns of
Care Study; RT: radiation therapy; CT: chemotherapy; SX: surgery; RX: treatment.
20
42
98
130
107
(5.0%)
(10.5%)
(24.5%)
(32.5%)
(26.8%)
50.4 Gy
(Range 5 6.0–96.7 Gy)
237
121
9
26
1.8 Gy
(59.3%)
(30.3%)
(2.3%)
(6.5%)
(Range 5 1.25–6.5 Gy)
40.5 days
(Range 5 1–123 days)
No. of
patients (%)
A
Non-A
34 (8.5%)
29 (7.3%)
10 Gy
(10–26 Gy
2
(2–4)
5 (1.2%)
8 (4%)
7 (3.5%)
15 Gy
(10–26 Gy)
2
(2–3)
1 (0.5%)
26 (12.8%)
22 (11%)
10 Gy
(5–25 Gy)
2
2–4)
4 (2%)
A: academic; Non-A: nonacademic; RT: radiotherapy; MV: megavolts; Gy: gray; HDR: high-dose-rate
brachytherapy; LDR: low-dose-rate brachytherapy.
a
P 5 0.002.
(not accounted for in this study) is an effective tumor
localization procedure.
Regarding management, this study demonstrated
that chemotherapy and radiation is the most frequently used regimen in the treatment of esophageal
carcinoma. Fifty-four percent of all patients received
chemotherapy and radiation; 21% received radiation
alone; 20% had surgery, radiation, and chemotherapy;
and 5% had surgery and radiation. Chemotherapy and
radiation was the most frequently used treatment regardless of stage or histology.
It is interesting to compare results of this PCS
study with those of the American College of Surgeons
Commission on Cancer and the American Cancer Society (ACS), as reported by Daly et al.13 (Table 8). They
analyzed 5256 cases of esophageal carcinoma treated
in 1993 and accrued to the National Cancer Data Base.
These cases represented nearly half of the patients
with esophageal carcinoma treated in the U.S. in 1993.
The findings of the study of Daly et al. are remarkably
similar to those of the PCS study presented herein. Of
8 possible treatment regimens listed in Table 8, ranging from surgery alone to trimodality treatment, they
also found that the combination of radiation therapy
and chemotherapy was the most frequently used
treatment. A comparison of the percentage of patients
treated with radiation alone, surgery and radiation,
radiation and chemotherapy, or all three modalities in
the two studies can be made by eliminating patients
who were not treated with radiation in the study of
Daly et al. In both studies, approximately 20% of patients received radiation alone, less than 10% received
surgery plus radiation, more than half received radiation plus chemotherapy, and roughly 20% received
trimodality treatment. The remarkable similarity in
the results attest to the power of the methodology of
this PCS study, which established the treatment usage
frequency from a much more limited sample size (in
this case, 400 patients vs. over 5000 patients.)
CRT should be used more frequently than radiation alone, as the Herskovic et al. trial demonstrated
superior results with CRT for the great majority of
patients with esophageal carcinoma. That study involved patients with Stages I–III esophageal carci-
Radiation for Esophageal Carcinoma/Coia et al.
noma and included both squamous cell carcinoma
and adenocarcinoma histologies (although only 15%
of patients had adenocarcinoma). Evidence of the sustained benefit of CRT was published by Al-Sarraf et al.
who reported long term results of the Intergroup trial.14 However, the appropriate relative frequency of
the use of CRT to radiation alone is unknown, as some
patients may not be candidates for chemotherapy due
to medical condition, performance status, or other
factors. This PCS study confirmed that CRT alone is
used more frequently than radiation alone (45% vs.
20%). Furthermore, there was no difference in the
frequency of use of CRT alone between academic and
nonacademic facilities. PCS plans to restudy the issue
to determine whether the relative use of CRT over
radiation alone will change over time.
Overall, CRT (alone, preoperative, or postoperative) was given somewhat more frequently at academic than nonacademic facilities (67% vs. 58%), predominantly due to its more frequent use at academic
institutions in the preoperative setting. In particular,
trimodality treatment was used more than twice as
frequently for patients with adenocarcinoma than for
those with squamous cell carcinoma. The use of preoperative CRT has been shown to be superior to surgery alone in two randomized studies; in one study
only patients with adenocarcinoma were included,15
and in the other approximately three-fourths of patients had adenocarcinoma.16 Nonetheless, the value
of preoperative CRT compared with surgery alone remains controversial and is being investigated further
in a current Intergroup study.
This study successfully determined the national
practice patterns for patients with esophageal carcinoma. Changes in the evaluation and treatment of
esophageal carcinoma patients continue, and PCS
plans to examine these changes with a future process
survey of patients with esophageal carcinoma treated
in 1996 –1997. The current analysis will also serve as a
useful benchmark to compare with evaluation and
treatment given in other countries, particularly Japan,
where the histologic presentation and management of
disease differ substantially from that observed in the
U.S. Such studies will give us further insight into how
we may better evaluate and treat patients with esophageal carcinoma.
2505
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