"Esophageal cancer is a tough cancer to treat," says lead researcher Peter Clark, MD, from the Clatterbridge Centre for Oncology in Merseyside, near Liverpool, England. The study was conducted for the MRC Clinical Trials Unit, based in London. "It is relatively common and frequently inoperable. We had one simple question with this study," Clark says, "does pre-surgical chemotherapy extend survival? The short answer is yes."

Clark’s group treated 802 patients with cancer of the esophagus in 40 medical centers across Europe between 1992 and 1998. Half of the patients got two courses of chemotherapy three weeks apart, then had their cancer surgically removed. The other half had standard treatment for advanced esophageal cancer, which is the surgery without preoperative chemotherapy.

The surgery-only group survived a median of 13.3 months after surgery compared to 17.2 months for the chemotherapy plus surgery (CS) group. Two years after surgery, only 34% of the patients who did not receive chemotherapy were still alive. Patients in the CS group did better. In this group, 43% were still alive two years after surgery. That translated into a 22% reduction on the risk of death at the two-year checkpoint for patients who got chemotherapy before surgery. One possible reason, according to Clark, is that after treatment with cisplatin plus 5-FU, 78% of patients were able to have their cancer completely removed, compared to 70% of surgery-only patients. "Significantly more patients in the surgery [only] group were inoperable or had incomplete removal of their cancers," Clark notes.

The survival advantage for CS patients seems to continue over time. Clark and his researchers have followed patients in the study for a median of 3.1 years. Over that period, 27% of CS patients were alive with no recurrence of their cancer, compared to 18% of surgery-only patients who remained free of cancer.

"The study showed a definite benefit from chemotherapy before surgery," says Herman Kattlove, MD, oncologist and medical editor at the American Cancer Society (ACS). "It may very well become the new standard of care if these results can be confirmed by other studies."

The ACS expects 13,200 new cases of esophageal cancer in the US this year and about 12,500 deaths. This cancer is three times more common in men than in women and three times more common among African Americans than among whites in this country. Rates are 10 to 100 times higher in Iran, northern China, India, and southern Africa.