Targeting therapy for esophageal cancer in patients aged 70 and over

BackgroundWhile cancer is a disease of the elderly, these patients are under-represented in randomized trials. Esophageal cancer-management in the elderly is challenging because of the morbidity and mortality associated with surgery.ObjectivesWe examined a strategy of neo-adjuvant chemo-radiotherapy (naCRT), followed by surgery or surveillance, in selected patients with cancer aged 70 and older.MethodsA prospectively-accrued database identified 56 consecutive patients over a 90-month period, who were aged 70 years and over, presented with esophageal carcinoma and were treated with neo-adjuvant CRT (naCRT) ± surgery.ResultsOf 129 eligible patients, 66 (51%) received palliative measures, while 63 (49%) had curative intervention, namely 7 had surgery and 56 had naCRT ± surgery. Of these 56 patients, 33 (59%) had adenocarcinoma (AC) and 23 (41%) had squamous cell carcinoma (SCC). Twenty-five (45%) had a complete clinical response (cCR), of which 6 had immediate resection; 4 (67%) had a complete pathological response (pCR); 19 patients with a cCR declined or were unfit for surgery and underwent surveillance; of these, 3 had interval esophagectomy; 16 were not offered or declined resection. Eight (50%) have survived ≥ 3 years. Mean overall survival was 28 months for the entire cohort; 47 months for cCRs; 61 months for patients undergoing primary resection, 46 months for cCRs who did not undergo resection and 29 months for those undergoing interval resection for recurrent disease. In cCRs, surgery did not provide a survival advantage (p = 0.861).ConclusioncCR yields an overall 3-year survival of 50% without operation. As 45% of patients have a cCR to naCRT, obligatory resection in high-risk cCR patients makes little sense. With the option for salvage esophagectomy in re-emergent disease, this selective strategy is an attractive alternative for elderly patients with cancer.