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Table of Contents
LETTER TO EDITOR
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 166-167

Neoadjuvant chemoradiation followed by surgery in operable carcinoma esophagus: Is the real-world scenario too far from clinical trial settings?


Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India

Date of Submission24-Jan-2022
Date of Decision25-Jan-2022
Date of Acceptance26-Jan-2022
Date of Web Publication31-Mar-2022

Correspondence Address:
Tapesh Bhattacharyya
Tata Medical Center, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_48_22

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How to cite this article:
Bhattacharyya T, Mallick I, Singh MA. Neoadjuvant chemoradiation followed by surgery in operable carcinoma esophagus: Is the real-world scenario too far from clinical trial settings?. Cancer Res Stat Treat 2022;5:166-7

How to cite this URL:
Bhattacharyya T, Mallick I, Singh MA. Neoadjuvant chemoradiation followed by surgery in operable carcinoma esophagus: Is the real-world scenario too far from clinical trial settings?. Cancer Res Stat Treat [serial online] 2022 [cited 2022 May 28];5:166-7. Available from: https://www.crstonline.com/text.asp?2022/5/1/166/342403



With great interest, we read the article by Dora et al.[1] and the accompanying editorial[2] on the real-world data of neoadjuvant chemoradiotherapy followed by surgery in operable carcinoma esophagus. The authors have discussed the challenges they faced in completing the planned treatment due to the lack of an in-house facility for esophageal cancer surgery. They have also reported impressive pathological complete responses in patients who underwent surgery after neoadjuvant chemoradiation.

However, we have some concerns regarding the results. Of 55 patients who were considered for this analysis, 53 patients were actually planned for the CROSS protocol. Unfortunately, only 32 patients (58%) could undergo esophageal surgery and thus, could complete the planned treatment. The standard radiotherapy dose for definitive chemoradiation in carcinoma esophagus is 50 Gy with conventional fractionation.[2] In the current study, the 23 patients (42%) who could not undergo surgery and only completed chemoradiation received a suboptimal external beam radiotherapy dose of 41.4 Gy in 23 fractions over 4½ weeks. We understand that as this rural tertiary care center lacks an in-house thoracic surgery facility, compliance to surgery was really poor. Approximately 16% of patients (9/55) did not undergo surgery according to the patients' wishes, which could have been much improved with in-house surgical counseling. The pathological complete response rate (60%) may have been different with an increased number of surgeries to add to the denominator.

Of 55 patients, 22 were lost to follow-up and their recurrence pattern could not be documented which is one of the major drawbacks of this study. The outcomes may have been quite different if the patients had been optimally followed up. This again highlights the need for improvement in our follow-up system to be able to collect more robust real-world data for future research.

Interestingly, the authors have mentioned that the median disease-free survival (DFS) in Group A (patients who underwent surgery) and Group B (patients who did not undergo surgery) was 8 months (range, 0–38) and 14 months (range, 0–29), respectively, and the 2 year DFS was 57.8% and 73.3%, respectively. We find it hard to understand the reason behind such a paradoxical result, especially since approximately 40% of the overall cohort of patients was lost to follow-up.

We would appreciate it if the authors could provide us with the baseline T and N stages separately along with the composite staging and the proportion of patients who met the actual CROSS eligibility criteria. The comparison of outcomes between CROSS-eligible and CROSS-ineligible patients in the real-world scenario could be another important aspect of this study. Our group had recently reported that the CROSS protocol is not just applicable to the trial setting, but it is also a reasonable option for carefully selected patients with more advanced disease in real-life scenarios which occur commonly in low-or middle-income countries with limited resources and where screening programs are not well-developed or strictly implemented.[3]

The authors have appropriately described the postoperative complications; however, they have not provided the details of the toxicities of neoadjuvant chemoradiation. We would like to know the details of hematological and gastrointestinal toxicities, along with the compliance to treatment. Readers will also be interested to know what proportion of patients were able to receive all five cycles of concurrent chemotherapy and how many required dose reductions.

I must commend the authors for sharing their real-world experience of using trimodality therapy for carcinoma esophagus. These results will form the foundation for future clinical research in our country, rather than trying to fit our patients into the shoes designed by the West.[4]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dora TK, Aeron T, Chatterjee A, Deshmukh J, Goel A, Bose S, et al. Neoadjuvant chemoradiotherapy followed by surgery for operable carcinoma esophagus: Ground reality in a tertiary care center of rural India – A retrospective audit. Cancer Res Stat Treat 2021;4:647-55.  Back to cited text no. 1
  [Full text]  
2.
Cooper JS, Guo MD, Herskovic A, Macdonald JS, Martenson JA Jr., Al-Sarraf M, et al. Chemoradiotherapy of locally advanced esophageal cancer: Long-term follow-up of a prospective randomized trial (RTOG 85-01). Radiation therapy oncology group. JAMA 1999;281:1623-7.  Back to cited text no. 2
    
3.
Bhattacharyya T, Arunsingh M, Chakraborty S, Harilal V, Sasidharan R, Saha S, et al. Can the CROSS protocol be safely implemented in real world scenario with broader eligibility criteria? Experience from a tertiary care centre in India. Ecancermedicalscience 2021;15:1291.  Back to cited text no. 3
    
4.
Noronha V. Making a case for cancer research in India. Cancer Res Stat Treat 2018;1:71-4.  Back to cited text no. 4
  [Full text]  




 

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