Clinical Oncology(1992) 4:114-118 © 1992The RoyalCollegeof Radiologists
Clinical Oncology
Original Article The Role of Radiotherapy in Carcinoma of the Thoracic Oesophagus: An Audit of the Mount Vernon Experience 1980-1989 M. D. Leslie, S. Dische, M. I. Saunders, E. Grosch, D. Fermont, R. F. U. Ashford and E. J. Maher Marie Curie Research Wing, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex HA6 2RN, UK
Abstract. All 244 patients with carcinoma of the thoracic oesophagus registered at the Mount Vernon Centre for Cancer Treatment during the decade from 1 January 1980 to 31 December 1989 have been audited. We have made a detailed analysis of 110 (45%) with localized disease considered unsuitable for surgery, who completed treatment solely by radiotherapy. The median survival of this group of patients was 8.2 months (range 0.2-54 months). Dysphagia was improved by radiotherapy in 77.3% of cases, the median duration of relief was 24 weeks (range 0-208 weeks) and was maintained until death in 40%. Life table analysis showed that radical compared with less than radical regimens of radiotherapy gave significantly superior relief of dysphagia. This result is unlikely to be due to case selection.
siderable case selection is made at the district hospital level and so nearly all those attending at Mount Vernon have already been considered suitable for radiotherapy. An audit has been made of all cases of carcinoma of the thoracic oesophagus seen during the ten year period 1 January 1980 to 31 December 1989. We have considered patient and tumour characteristics, treatment intent (radical or palliative, the radiotherapy given and the outcome in terms of survival and palliation of dysphagia.
Keywords: Carcinoma of the thoracic oesophagus; Dysphagia; Medical audit; Radiotherapy; Survival
The Mount Vernon Cancer Registry data was used to identify all patients with carcinoma of the thoracic oesophagus registered between 1 January 1980 and 31 December 1989. Of the total of 244 patients, 110 with no evidence of metastatic disease beyond the mediastinum, and who completed treatment solely by radiotherapy, were studied further to assess its effect on relief of dysphagia and survival. All patients have been followed up for a minimum of one year after treatment. Dysphagia was scored according to a scale which has been successfully employed in our centre and which is now part of a proposed international system
INTRODUCTION The number of deaths from carcinoma of the oesophagus in England and Wales has risen substantially over the last ten years, probably due to the increase in the number of elderly people in the population. There were 3621 deaths in 1977 [1] compared with 4770 deaths registered in 1987 [2]. The overall 5-year survival for unselected patients is about 5%, irrespective of the treatment modality used [3, 4]. Survival is not the only endpoint by which to judge the benefit of treatment in these patients, for their quality of life can be markedly improved by relief of dysphagia. The Centre for Cancer Treatment at Mount Vernon Hospital serves a population of approximately 2 million people, and, in all, over 5000 new cancer patients are seen each year at Mount Vernon and the 11 district general hospitals attended, ConCorrespondence and offprint requests to: Dr. M. D. Leslie, Research Fellow and Honorary Senior Registrar, Marie Curie Research Wing, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital,Northwood,MiddlesexHA6 2RN, UK.
PATIENTS AND METHODS
[51: 0 1 2 3 4
None Discomfort on swallowing, no disturbance of diet Difficulty swallowing, soft diet required Considerable difficulty swallowing, fluids only Severe difficulty with fluids
All data was recorded on proformas, and entered and stored on a Microvax II (Digital) computer. The duration of dysphagia relief and survival was analyzed by the life table method and significance determined by the log-rank test [6]. A variety of regimens of radiotherapy were employed. The choice was determined by the responsible consultant and influenced by the purpose of treatment. In these patients with apparently localized disease, the domi-
Radiotherapy in Carcinoma of the Thoracic Oesophagus
115
nant factors which influenced the decision to treat with radical or palliative intent were age and general condition. With increasing work-load over the decade there has been a trend to employ a limited number of treatment fractions in palliative cases. In 1985 the CHART (continuous hyperfractionated accelerated radiotherapy) regimen was introduced, mainly for patients with cancer of the head and neck or bronchus. However, 10 cases of carcinoma of the thoracic oesophagus included in this study were so treated. All patients were planned for treatment using a stimulator and all were treated on megavoltage equipment.
radiotherapy had been given to 5 patients, and 4 with locally advanced inoperable adenocracinomas of the lower oesophagus had been treated with combination chemotherapy only. There remained 140 patients who were referred for consideration of radiotherapy as the sole treatment of their primary tumour. However, on further investigation 21 were found to have disease outside the thorax and were thus treated with a simple palliative course of radiotherapy. In 9 other cases, although a decision was made for treatment, it was not completed; 2 died before radiotherapy was commenced, 5 died during the course of treatment and in 2 other cases the development of total dysphagia led to intubation and radiotherapy was abandoned. The remaining 110 patients were studied in greater depth.
RESULTS Patient Characteristics The clinical groupings of all patients seen at the Cancer Treatment Centre and the treatment they received is shown in Fig. 1. There were 25 patients who were referred because of recurrence in the mediastinum following previous surgery and 12 who came for radiotherapy postoperatively because of positive resection margins and/or residual mediastinal disease. Palliative radiotherapy was given to sites of metastatic disease in 28 patients who showed dissemination at the time of referral. Prior to referral, 26 patients had been intubated and 4 had undergone a surgical bypass procedure. Preoperative
The mean age was 72 years (range 48.9-93.9 years) and the female:male ratio 1.2:1.0. The mean time for first symptom to diagnosis was 13.5 weeks (range 248 weeks) and the mean weight loss at diagnosis was 8.6 kg (range 0-22 kg). The presenting symptoms were dysphagia in 110 (100%), weight loss in 102 (93%) and vomiting/regurgitation in 32 (29%). The dysphagia score at presentation is shown in Fig. 2. The reasons given for surgery not being performed were age/poor general condition in 62 (56%), extent of the lesion in 22 (20%), coincidental disease in 17
TOTAL NUMBER OF CASES SEEN AT THE CANCER TREATMENT CENTRE 244
I I I SURGICAL INTUBATED PRE-OP BYPASS PRIORTO RT PRIORTO FIT RT 4 26 5
I POST-OP RT
I I
I
I I CENTRAL RT FOR RECURRENCE DISTANT AFTER METASTASES SURGERY 25
12
I CHEMOTHERAPY ALONE 4
28
DEFINITIVE TREATMENT ENTIRELY BY RADIOTHERAPY 140
EXTRA'rHOEACICDISEASE FOUNDPRIORTO RT 21
I
I
I
DEA'n'I PRIOR DEATHPRIOR RTABANDONED TO COMMENCING TO COMPLE'IING AND PATIENT RT RT INTUBATED 2 5 2
I
NO EXTRATHORACIC DISEASE AND TREATMENT COMPLETED WITH RT 110
Fig. 1. Clinical groupings of patients with carcinoma of the thoracic oesophagus seen at the Cancer Treatment Centre between 1980-1989.
116
M. D. Leslie et al.
70~60~==
2O
65
~
50~-
O
47Patients
.... 17
40~.e" O
etP
60-65Gy/30-32fractions 5 per week
50-60Gy/20-30fractions 4-5per week 54Gy/36fractions 3per day (CHART)
30"*'
30-35Gy/6fractions
20~' IINTERMEDIATE ~=- 30Patients
10~' 0~o
0
1
2
3
4
.
:---;-i-t---7 ..... i
"O
"6
60
L:t
111
E
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lk i
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•-E 20
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0
. . . . . . . . .
0
i
. . . . . . . . .
20
i
40
. . . . . . . . .
i
60
. . . . . . . . .
,
80
. . . . . . . . .
i
100
Duration of i m p r o v e m e n t (weeks)
Fig. 5. Life table showing the maintenance of relief of dysphagia for the first 100 weeks following radiotherapy, according to treatment schedule. Palliative ....... ~30 Gy 50 Gy.
'radical' course of treatment as compared with 'palliative' or 'intermediate' treatment schedules (P=0.043).
Survival/Cause
of Death
The median survival of all cases was 8.2 months (range 0.2-54 months). At the time of this analysis (November 1990) 5 patients remain alive; 2 at 1 year, 2 at 3 years and 1 who underwent salvage surgery is alive at 4.5 years. A post-mortem was carried out in only 13 (12.4%) patients who died, but clinical data regarding the circumstances leading to death was available in all but 17 (16%) of them. The primary tumour seemed responsible for death in 43 (41%) of patients, and secondaries in 27 (26%). Coincidental disease accounted for 14 (13%) of deaths (ischaemic heart disease in 8, chronic obstructive airways disease in 4 and carcinoma of the bronchus in 2); in 6 of the 14 cases, tumour was present and contributed to death. There were no deaths from radiotherapy complications but 4 (4%) resulted from other treatment complications (1 following oesophagectomy and 3 following tumour intubation).
The standard management for carcinoma of the thoracic oesophagus in our region over the decade of this study was surgical resection. In no 'operable' case was radiotherapy considered the preferred treatment modality and it was employed for those in whom resection was not possible, either because of the extent of the tumour or patient unsuitability. We studied 110 patients for whom radiotherapy was the sole treatment method to assess the effectiveness of treatment. Of these, 70% were directly referred by surgeons who had considered resection. In over half of all the patients, either age or poor general condition was the main reason for not proceeding with surgery; in a further 20% it was extent of the lesion. Consequently, our patients were relatively old, with a mean age of 72 years, and tumours were locally advanced, with a mean length of 6.6 cm. As must be expected, the overall survival was poor with a median duration of 8.2 months. The median survival of our patients treated by a 'radical' schedule was 10.3 months compared with 7.0 months for those treated by a 'palliative' or an 'intermediate' schedule, reflecting the selection of patients for these schedules. Dysphagia was improved by radiotherapy in 77 (77.3%) of the 97 assessable patients, and 37 (40%) of the 92 that died maintained relief of dysphagia until death. Caspers and colleagues [8] found similar results in their series of patients with oesophageal cancer treated by radiotherapy, with an improvement in dysphagia seen in 74 (70.5%) of 105 patients. As in this study, they were able to demonstrate a more prolonged relief of dysphagia in patients treated to a relatively high dose of 50 Gy or more. This dose-dependance of duration of dysphagia relief has also been described by Albertsson and coworkers. It would not seem to represent simply patient selection, for there were only small and not significant differences in tumour length in our three treatment groups. The criteria used for selecting the treatment schedule was primarily the patient's generaly condition and expected survival; these are not factors that would influence relief of dysphagia. The 'intermediate' regimens of radiotherapy were employed as a compromise between an intention to achieve long term tumour control and the need to reduce the number of attendances for treatment, so minimizing stress upon the patient and the facilities of the treatment centre. In both survival and relief of dysphagia they appear to convey no advantage over the 'palliative' regimens. Although radical regimens appear to give superior palliation, they require longer periods of attendance and therefore a greater use of resources. There may also be a longer interval before the resolution of oesophageal reaction to radiotherapy occurs. The use of radical treatment schedules is not appropriate where expectation of survival is short, when palliative regimens given over periods of two weeks or less should be used. Compared with the other 37 patients treated by a radical schedule of radiotherapy the median survival of the 10 patients treated by C H A R T was marginally greater at 12 instead of 10 months, but relief of
118 dysphagia was maintained longer in the C H A R T group with a median 40.5 weeks compared with 30 weeks. The C H A R T schedule seems particularly well suited for these patients, it being completed in a short period of time with early relief of dysphagia and little morbidity from treatment. Further study is in progress with the addition of Mitomycin-C to the C H A R T schedule. No prospective randomized trial of radiotherapy versus surgery for operable squamous cell carcinoma of the oesophagus has ever been conducted and it is difficult to compare surgical with radiotherapy series because of patient selection [10]. In a recent review of 1201 papers from the world literature on the surgical treatment of oesophageal carcinoma the survival for resected cases was 48% at i year, 21% at 2 years and 18% at 5 years [11]. Of our 47 patients treated radically by radiotherapy, 42% were alive at i year, 20% at 2 years but there were none alive at 5 years. Taking into account that our patients were rejected for surgical resection, the results are remarkably similar for the first 2 years. Where radiotherapy is employed as the definitive treatment, better results can be achieved. Pearson [12] reported a five-year survival of 19% with radiotherapy in the treatment of selected squamous cell lesions and long term survivors have been recorded in other radiotherapy series [13, 14]. The controversy regarding surgery versus radiotherapy for squamous cell carcinoma of the oesophagus continues [15]. It is of interest that a recent cost comparison found that surgical resection was on average almost four times more costly than radical radiotherapy [16]. If further experience with the pilot studies of C H A R T , including the addition of Mitomycin-C, suggests a superiority over conventional radiotherapy, then a comparison with surgery will be indicated. This audit has shown the range of situations for which patients with carcinoma of the thoracic oesophagus considered unsuitable for surgery were referred to an oncology centre. Patients with localized disease and a satisfactory general condition, but who are unsuitable for surgery, can be given valuable palliation by radiotherapy. It seems that more durable relief of dysphagia can be achieved by the use of a radical rather than a palliative treatment schedule.
M.D. Leslie et al.
Acknowledgements.
We wish to thank all our colleagues at district hospitals for their continued cooperation, Miss Anita Elespe for statistical analysis of the data, and the staff of the Cancer Registry for obtaining the case records.
References 1. Office of Population Censuses and Surveys. Mortality statistics cause. England and Wales. Series DH2 No 4. London: HMSO, 1977. 2. Office of Population Censuses and Surveys. Mortality statistics cause. England and Wales. Series DH2 No 14. London: HMSO, 1987. 3. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma: I. A. critical review of surgery. Br J Surg 1980; 67:381-90. 4. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma: II. A critical review of radiotherapy. Br J Surg 1980; 67:457-61. 5. Dische S, Warburton MF, Jones D, et al. The recording of morbidity related to radiotherapy. Radiother Oncol 1989; 16:103-8. 6. Peto R, Pike MC, Armitage P, et al. Design and analysis of randomized clinical trials requiring prolonged observation of each patient: II. Br J Cancer 1977; 35:1-39. 7. UICC.TNM-atlas. 2nded. NewYork: Springer-Verlag, 1982. 8. Caspers RJL, Welvaart K, Verkes RJ, et al. The effect of radiotherapy on dysphagia and survival in patients with esophageal cancer. Radiother Oncol 1988; 12:15-23. 9. Albertsson M, Ewers SB, Widmark H, et al. Evaluation of the palliative effect of radiotherapy for esophageal carcinoma. Acta Oncol 1989; 28:267-70. 10. Earlam R. An MRC prospective randomised trial of radiotherapy versus surgery for operable squamous cell carcinoma of the oesophagus. Ann R Coll Surg Engl 1991; 73:8-12. 11. Muller JM, Erasmi H, Stelzner M, et al. Surgical therapy of oesophageal carcinoma. Br J Surg 1990; 77:845-57. 12. Pearson JG. The present status and future potential of radiotherapy in the management of esophageal cancer. Cancer 1977; 39:882-90. 13. NewaishyGA, Read GA, Duncan W, et al. Results of radical radiotherapy of squamous cell carcinoma of the oesophagus. Clin Radiol 1982; 33:347-52. 14. SlevinNJ, Stout R. Carcinomaof the oesophagus- a reviewof 108 cases treated by radical radiotherapy. Clin Radiol 1989; 40:200-3. 15. CuschieriA. Invited introduction: Treatment of carcinomaof the oesophagus. Ann R Coll Surg Engl 1991; 73:1-3. 16. Walker QJ, Salkeld G, Hall J, et al. The management of oesophageal carcinoma: radiotherapy or surgery? Cost considerations. Eur J Cancer Clin Oncol 1989; 25:1657-62.
Received for publication April 1991 Accepted August 1991
Clinical Oncology
Original Article The Role of Radiotherapy in Carcinoma of the Thoracic Oesophagus: An Audit of the Mount Vernon Experience 1980-1989 M. D. Leslie, S. Dische, M. I. Saunders, E. Grosch, D. Fermont, R. F. U. Ashford and E. J. Maher Marie Curie Research Wing, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex HA6 2RN, UK
Abstract. All 244 patients with carcinoma of the thoracic oesophagus registered at the Mount Vernon Centre for Cancer Treatment during the decade from 1 January 1980 to 31 December 1989 have been audited. We have made a detailed analysis of 110 (45%) with localized disease considered unsuitable for surgery, who completed treatment solely by radiotherapy. The median survival of this group of patients was 8.2 months (range 0.2-54 months). Dysphagia was improved by radiotherapy in 77.3% of cases, the median duration of relief was 24 weeks (range 0-208 weeks) and was maintained until death in 40%. Life table analysis showed that radical compared with less than radical regimens of radiotherapy gave significantly superior relief of dysphagia. This result is unlikely to be due to case selection.
siderable case selection is made at the district hospital level and so nearly all those attending at Mount Vernon have already been considered suitable for radiotherapy. An audit has been made of all cases of carcinoma of the thoracic oesophagus seen during the ten year period 1 January 1980 to 31 December 1989. We have considered patient and tumour characteristics, treatment intent (radical or palliative, the radiotherapy given and the outcome in terms of survival and palliation of dysphagia.
Keywords: Carcinoma of the thoracic oesophagus; Dysphagia; Medical audit; Radiotherapy; Survival
The Mount Vernon Cancer Registry data was used to identify all patients with carcinoma of the thoracic oesophagus registered between 1 January 1980 and 31 December 1989. Of the total of 244 patients, 110 with no evidence of metastatic disease beyond the mediastinum, and who completed treatment solely by radiotherapy, were studied further to assess its effect on relief of dysphagia and survival. All patients have been followed up for a minimum of one year after treatment. Dysphagia was scored according to a scale which has been successfully employed in our centre and which is now part of a proposed international system
INTRODUCTION The number of deaths from carcinoma of the oesophagus in England and Wales has risen substantially over the last ten years, probably due to the increase in the number of elderly people in the population. There were 3621 deaths in 1977 [1] compared with 4770 deaths registered in 1987 [2]. The overall 5-year survival for unselected patients is about 5%, irrespective of the treatment modality used [3, 4]. Survival is not the only endpoint by which to judge the benefit of treatment in these patients, for their quality of life can be markedly improved by relief of dysphagia. The Centre for Cancer Treatment at Mount Vernon Hospital serves a population of approximately 2 million people, and, in all, over 5000 new cancer patients are seen each year at Mount Vernon and the 11 district general hospitals attended, ConCorrespondence and offprint requests to: Dr. M. D. Leslie, Research Fellow and Honorary Senior Registrar, Marie Curie Research Wing, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital,Northwood,MiddlesexHA6 2RN, UK.
PATIENTS AND METHODS
[51: 0 1 2 3 4
None Discomfort on swallowing, no disturbance of diet Difficulty swallowing, soft diet required Considerable difficulty swallowing, fluids only Severe difficulty with fluids
All data was recorded on proformas, and entered and stored on a Microvax II (Digital) computer. The duration of dysphagia relief and survival was analyzed by the life table method and significance determined by the log-rank test [6]. A variety of regimens of radiotherapy were employed. The choice was determined by the responsible consultant and influenced by the purpose of treatment. In these patients with apparently localized disease, the domi-
Radiotherapy in Carcinoma of the Thoracic Oesophagus
115
nant factors which influenced the decision to treat with radical or palliative intent were age and general condition. With increasing work-load over the decade there has been a trend to employ a limited number of treatment fractions in palliative cases. In 1985 the CHART (continuous hyperfractionated accelerated radiotherapy) regimen was introduced, mainly for patients with cancer of the head and neck or bronchus. However, 10 cases of carcinoma of the thoracic oesophagus included in this study were so treated. All patients were planned for treatment using a stimulator and all were treated on megavoltage equipment.
radiotherapy had been given to 5 patients, and 4 with locally advanced inoperable adenocracinomas of the lower oesophagus had been treated with combination chemotherapy only. There remained 140 patients who were referred for consideration of radiotherapy as the sole treatment of their primary tumour. However, on further investigation 21 were found to have disease outside the thorax and were thus treated with a simple palliative course of radiotherapy. In 9 other cases, although a decision was made for treatment, it was not completed; 2 died before radiotherapy was commenced, 5 died during the course of treatment and in 2 other cases the development of total dysphagia led to intubation and radiotherapy was abandoned. The remaining 110 patients were studied in greater depth.
RESULTS Patient Characteristics The clinical groupings of all patients seen at the Cancer Treatment Centre and the treatment they received is shown in Fig. 1. There were 25 patients who were referred because of recurrence in the mediastinum following previous surgery and 12 who came for radiotherapy postoperatively because of positive resection margins and/or residual mediastinal disease. Palliative radiotherapy was given to sites of metastatic disease in 28 patients who showed dissemination at the time of referral. Prior to referral, 26 patients had been intubated and 4 had undergone a surgical bypass procedure. Preoperative
The mean age was 72 years (range 48.9-93.9 years) and the female:male ratio 1.2:1.0. The mean time for first symptom to diagnosis was 13.5 weeks (range 248 weeks) and the mean weight loss at diagnosis was 8.6 kg (range 0-22 kg). The presenting symptoms were dysphagia in 110 (100%), weight loss in 102 (93%) and vomiting/regurgitation in 32 (29%). The dysphagia score at presentation is shown in Fig. 2. The reasons given for surgery not being performed were age/poor general condition in 62 (56%), extent of the lesion in 22 (20%), coincidental disease in 17
TOTAL NUMBER OF CASES SEEN AT THE CANCER TREATMENT CENTRE 244
I I I SURGICAL INTUBATED PRE-OP BYPASS PRIORTO RT PRIORTO FIT RT 4 26 5
I POST-OP RT
I I
I
I I CENTRAL RT FOR RECURRENCE DISTANT AFTER METASTASES SURGERY 25
12
I CHEMOTHERAPY ALONE 4
28
DEFINITIVE TREATMENT ENTIRELY BY RADIOTHERAPY 140
EXTRA'rHOEACICDISEASE FOUNDPRIORTO RT 21
I
I
I
DEA'n'I PRIOR DEATHPRIOR RTABANDONED TO COMMENCING TO COMPLE'IING AND PATIENT RT RT INTUBATED 2 5 2
I
NO EXTRATHORACIC DISEASE AND TREATMENT COMPLETED WITH RT 110
Fig. 1. Clinical groupings of patients with carcinoma of the thoracic oesophagus seen at the Cancer Treatment Centre between 1980-1989.
116
M. D. Leslie et al.
70~60~==
2O
65
~
50~-
O
47Patients
.... 17
40~.e" O
etP
60-65Gy/30-32fractions 5 per week
50-60Gy/20-30fractions 4-5per week 54Gy/36fractions 3per day (CHART)
30"*'
30-35Gy/6fractions
20~' IINTERMEDIATE ~=- 30Patients
10~' 0~o
0
1
2
3
4
.
:---;-i-t---7 ..... i
"O
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60
L:t
111
E
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lk i
40
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0
. . . . . . . . .
0
i
. . . . . . . . .
20
i
40
. . . . . . . . .
i
60
. . . . . . . . .
,
80
. . . . . . . . .
i
100
Duration of i m p r o v e m e n t (weeks)
Fig. 5. Life table showing the maintenance of relief of dysphagia for the first 100 weeks following radiotherapy, according to treatment schedule. Palliative ....... ~30 Gy 50 Gy.
'radical' course of treatment as compared with 'palliative' or 'intermediate' treatment schedules (P=0.043).
Survival/Cause
of Death
The median survival of all cases was 8.2 months (range 0.2-54 months). At the time of this analysis (November 1990) 5 patients remain alive; 2 at 1 year, 2 at 3 years and 1 who underwent salvage surgery is alive at 4.5 years. A post-mortem was carried out in only 13 (12.4%) patients who died, but clinical data regarding the circumstances leading to death was available in all but 17 (16%) of them. The primary tumour seemed responsible for death in 43 (41%) of patients, and secondaries in 27 (26%). Coincidental disease accounted for 14 (13%) of deaths (ischaemic heart disease in 8, chronic obstructive airways disease in 4 and carcinoma of the bronchus in 2); in 6 of the 14 cases, tumour was present and contributed to death. There were no deaths from radiotherapy complications but 4 (4%) resulted from other treatment complications (1 following oesophagectomy and 3 following tumour intubation).
The standard management for carcinoma of the thoracic oesophagus in our region over the decade of this study was surgical resection. In no 'operable' case was radiotherapy considered the preferred treatment modality and it was employed for those in whom resection was not possible, either because of the extent of the tumour or patient unsuitability. We studied 110 patients for whom radiotherapy was the sole treatment method to assess the effectiveness of treatment. Of these, 70% were directly referred by surgeons who had considered resection. In over half of all the patients, either age or poor general condition was the main reason for not proceeding with surgery; in a further 20% it was extent of the lesion. Consequently, our patients were relatively old, with a mean age of 72 years, and tumours were locally advanced, with a mean length of 6.6 cm. As must be expected, the overall survival was poor with a median duration of 8.2 months. The median survival of our patients treated by a 'radical' schedule was 10.3 months compared with 7.0 months for those treated by a 'palliative' or an 'intermediate' schedule, reflecting the selection of patients for these schedules. Dysphagia was improved by radiotherapy in 77 (77.3%) of the 97 assessable patients, and 37 (40%) of the 92 that died maintained relief of dysphagia until death. Caspers and colleagues [8] found similar results in their series of patients with oesophageal cancer treated by radiotherapy, with an improvement in dysphagia seen in 74 (70.5%) of 105 patients. As in this study, they were able to demonstrate a more prolonged relief of dysphagia in patients treated to a relatively high dose of 50 Gy or more. This dose-dependance of duration of dysphagia relief has also been described by Albertsson and coworkers. It would not seem to represent simply patient selection, for there were only small and not significant differences in tumour length in our three treatment groups. The criteria used for selecting the treatment schedule was primarily the patient's generaly condition and expected survival; these are not factors that would influence relief of dysphagia. The 'intermediate' regimens of radiotherapy were employed as a compromise between an intention to achieve long term tumour control and the need to reduce the number of attendances for treatment, so minimizing stress upon the patient and the facilities of the treatment centre. In both survival and relief of dysphagia they appear to convey no advantage over the 'palliative' regimens. Although radical regimens appear to give superior palliation, they require longer periods of attendance and therefore a greater use of resources. There may also be a longer interval before the resolution of oesophageal reaction to radiotherapy occurs. The use of radical treatment schedules is not appropriate where expectation of survival is short, when palliative regimens given over periods of two weeks or less should be used. Compared with the other 37 patients treated by a radical schedule of radiotherapy the median survival of the 10 patients treated by C H A R T was marginally greater at 12 instead of 10 months, but relief of
118 dysphagia was maintained longer in the C H A R T group with a median 40.5 weeks compared with 30 weeks. The C H A R T schedule seems particularly well suited for these patients, it being completed in a short period of time with early relief of dysphagia and little morbidity from treatment. Further study is in progress with the addition of Mitomycin-C to the C H A R T schedule. No prospective randomized trial of radiotherapy versus surgery for operable squamous cell carcinoma of the oesophagus has ever been conducted and it is difficult to compare surgical with radiotherapy series because of patient selection [10]. In a recent review of 1201 papers from the world literature on the surgical treatment of oesophageal carcinoma the survival for resected cases was 48% at i year, 21% at 2 years and 18% at 5 years [11]. Of our 47 patients treated radically by radiotherapy, 42% were alive at i year, 20% at 2 years but there were none alive at 5 years. Taking into account that our patients were rejected for surgical resection, the results are remarkably similar for the first 2 years. Where radiotherapy is employed as the definitive treatment, better results can be achieved. Pearson [12] reported a five-year survival of 19% with radiotherapy in the treatment of selected squamous cell lesions and long term survivors have been recorded in other radiotherapy series [13, 14]. The controversy regarding surgery versus radiotherapy for squamous cell carcinoma of the oesophagus continues [15]. It is of interest that a recent cost comparison found that surgical resection was on average almost four times more costly than radical radiotherapy [16]. If further experience with the pilot studies of C H A R T , including the addition of Mitomycin-C, suggests a superiority over conventional radiotherapy, then a comparison with surgery will be indicated. This audit has shown the range of situations for which patients with carcinoma of the thoracic oesophagus considered unsuitable for surgery were referred to an oncology centre. Patients with localized disease and a satisfactory general condition, but who are unsuitable for surgery, can be given valuable palliation by radiotherapy. It seems that more durable relief of dysphagia can be achieved by the use of a radical rather than a palliative treatment schedule.
M.D. Leslie et al.
Acknowledgements.
We wish to thank all our colleagues at district hospitals for their continued cooperation, Miss Anita Elespe for statistical analysis of the data, and the staff of the Cancer Registry for obtaining the case records.
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Received for publication April 1991 Accepted August 1991
