Preoperative Chemotherapy Plus Immunotherapy Found Effective in Esophageal Cancer

Esophageal cancer begins in the cells of the esophagus, the tube carrying food to the stomach. It is among the most common cancers worldwide and is often diagnosed at an advanced stage. According to Turkey Cancer Statistics, 1405 people were diagnosed with esophageal cancer in 2019.

There are two main types: squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma usually develops in the upper esophagus, while adenocarcinoma generally develops in the lower part near the stomach.

Most cases are advanced at diagnosis, influencing treatment strategy. Neoadjuvant treatment is often used in these patients. Neoadjuvant treatment is given before surgery, usually as radiotherapy or chemotherapy. It aims to shrink the tumor and make surgery more effective.

In recent years, neoadjuvant immunotherapy has emerged as a promising strategy in esophageal cancer. Immunotherapy uses the body's own immune system to fight cancer cells. When used before surgery, it is generally combined with chemotherapy.

However, precise data on the proportion of patients requiring neoadjuvant treatment at diagnosis are unavailable. Generally, many patients with locally advanced disease need it.

Neoadjuvant immunotherapies for esophageal cancer have not yet received FDA (US Food and Drug Administration) approval. Nevertheless, on May 20, 2021, the FDA granted approval for people with completely resected esophageal or GEJ (gastroesophageal junction) cancer who had received neoadjuvant chemoradiotherapy and had residual pathological disease, for adjuvant nivolumab (Opdivo) immunotherapy.

We now turn to an important development concerning neoadjuvant chemotherapy plus immunotherapy, presented in May 2023 at the American Association for Thoracic Surgery (AATS) Annual Meeting.

Neoadjuvant Chemoimmunotherapy Is Safe and Effective in Esophageal Cancer

New research indicates that neoadjuvant chemotherapy combined with an immune checkpoint inhibitor is safe and effective in patients with resectable esophageal cancer.

In this real-world study, patients received one of 4 different immunotherapies with preoperative chemotherapy. More than 75% were alive and free of any event after 1 year, and treatment was tolerable. Event-free survival is the time a patient remains without an event such as disease progression, recurrence or death.

The study included 177 patients with resectable esophageal cancer. Median age at surgery was 62; 132 patients were men and 45 were women.

Between January 2019 and January 2022, patients received chemotherapy with neoadjuvant pembrolizumab (57 patients), tislelizumab (47), camrelizumab (44) or sintilimab (29).

• Median follow-up was 14 months.
• The pathological complete response rate was 32.3% , meaning no cancer cells were found in the tumor tissue removed at surgery after neoadjuvant treatment. 
• The R0 resection rate was 99.4%. R0 resection means the tumor is completely removed, with no cancer cells remaining at the microscopic level.
• The 1-year event-free survival rate was 78.3%, and the 1-year overall survival rate was 88.0%.
• Postoperative complications occurred in 35.6%. Serious (grade 3 or higher) treatment-related adverse events occurred in 18.1%. These included leukopenia (7.9%), neutropenia (3.4%), thrombocytopenia (3.4%), anemia (2.8%) and hyperglycemia (0.6%).

These findings suggest that immunotherapy combined with neoadjuvant chemotherapy is tolerable and provides favorable short-term survival.

The findings indicate that neoadjuvant chemoimmunotherapy is a safe, effective option for patients with esophageal cancer. It may shrink tumors and make surgery more successful, further highlighting immunotherapy's potential in this disease.