Aspects on prognosis of cancers of the oesophagus and gastric cardia

Abstract

Oesophageal cancer is an aggressive form of cancer with a poor prognosis. The two main histological types are squamous-cell carcinoma and adenocarcinoma. In the Western world the incidence rate of adenocarcinoma of the oesophagus, previously rather rare, has shown a dramatic increase in recent decades. Despite improvements in staging and treatment modalities, the 5-year survival rate remains around 10% overall and 25-30% for patients treated with curative intent. Identification of prognostic factors is important in an attempt to improve the outcome for oesophageal cancer patients.

In the first study we evaluate prognostic trends of oesophageal cancer in Sweden. The Swedish Cancer Register was used to identify all cases of oesophageal adenocarcinoma or squamous-cell carcinoma between 1961 and 1996. We found a significantly improved observed survival for oesophageal adenocarcinoma during 1990-1996 (10.5%) compared to previous decades (4%) and also a corresponding slightly improved survival for squamous-cell carcinoma by each decade (from 3.8% in 1961-1969 to 7.0% in 1990-1996).

Prognostic factors were studied in Papers II and III. In Paper II the effects of surgical prognostic factors on short and long-term outcome after tumour resection were studied, while in Paper III the influence of patient demographic characteristics and lifestyle factors on prognosis was studied. The 757 cases of adenocarcinoma of the oesophagus and gastric cardia, and squamous-cell carcinoma of the oesophagus, reported to the Swedish Esophageal and Cardia Cancer (SECC) study were used as study base. In Paper II, 232 patients out of the total 757 were resected and became the study cohort. In Paper III, 580 patients (356 nonresected and 224 resected) out of the 618 interviewed patients were the study cohort. Overall observed survival during the time period was 12% and for the resected patients 25%. Patients treated in a high-volume setting, defined as ¡Ý10 oesophagectomies per year within the study period, had a modestly improved survival compared to patients treated in a low-volume setting. Need for post-operative ventilator support was a significant negative predictor of survival. Smoking and low educational level were negative predictors of survival in patients with squamous-cell carcinoma whilst obese patients diagnosed with adenocarcinoma of the oesophagus had a significantly improved survival compared to normal weight patients.

In the final study, palliation of dysphagia by placement of expandable metal stents was studied. During January 1993 to May 2005, 149 patients treated at a single institution were evaluated with regard to factors influencing morbidity, procedure-related mortality and symptom relief in terms of dysphagia. The procedure-related mortality was 3% and the complication rate 26%. Pre-treatment dysphagia improved in 70% of subjects (p<0.0001). Tumour length, tumour location, histology, age, gender or prior dilatation did not affect the outcome in terms of procedure-related morbidity or symptom relief.