Multiple Management Modalities in Esophageal Cancer: Combined Modality Management Approaches

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Abstract
Learning Objectives: After completing this course, the reader will be able to: Outline the relative merits of definitive radiation alone or as a preoperative or postoperative treatment for esophageal cancer versus combined chemoradiation in these settings. Discuss the limitations of our understanding of the radiation dose-response relationship in esophageal cancer. Appreciate the merits of chemoradiation as definitive treatment for esophageal cancer versus its use as an adjuvant to surgery. Access and take the CME test online and receive one hour of AMA PRA category 1 credit at http://CME.TheOncologist.com The overall success rate nationally in treating esophageal carcinomas remains poor, with over 90% of patients succumbing to the disease. In part I of this two-part series, we explored epidemiology, presentation and progression, work-up, and surgical approaches. In part II, we explore the promising suggestions of integrating chemotherapy and radiation therapy into the multimodal management of esophageal cancers. Alternative approaches to resection alone have been sought because of the overall poor survival rates of esophageal cancer patients, with failures occurring both local-regionally and distantly. Concomitant chemotherapy and radiation therapy (XRT) have been shown, by randomized trial, to be more effective than XRT alone in treating unresectable esophageal cancers and also have shown promise as a neoadjuvant treatment when combined with surgery in the multimodal treatment of this disease. Various studies have also addressed issues such as preoperative chemotherapy, radiation dose escalation, chemotherapy/XRT as a definitive treatment versus use as a surgical adjuvant, and alternative chemotherapy regimens. There are suggestions of some progress, but this remains a difficult problem area in which management is continuing to evolve.

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