eComment. Neoadjuvant chemoradiotherapy: where is the real controversy?

We read with great interest the article by Buderi et al. [1], “Does neoadjuvant chemoradiotherapy increase survival in patients with resectable oesophageal cancer?” The authors presented 11 up-to-date randomized controlled trials and concluded that neoadjuvant chemoradiotherapy followed by surgery for resectable oesophageal cancer offers similar or even improved survival results compared to surgery alone [1]. We identified other high-quality, relevant systematic reviews and meta-analyses, nearly all of which [2, 3] also concluded that neoadjuvant chemoradiotherapy followed by surgery provides significant survival benefits for patients with resectable oesophageal cancer compared with surgery alone. The National Comprehensive Cancer Network clinical practice guidelines in oncology for oesophageal and oesophagogastric junction cancers [4] also recommend neoadjuvant chemoradiotherapy as a preferred preoperative treatment strategy for patients with resectable, locally advanced oesphageal cancer. Consequently, we want to emphasize that neoadjuvant chemoradiotherapy did bring survival benefits to patients with resectable, locally advanced oesophageal cancer, not the similar survival results compared with surgery alone as concluded by Buderi et al. [1]. With regard to the concept of survival benefits of neoadjuvant chemoradiotherapy, many researchers began to question whether combining radiotherapy with neoadjuvant chemotherapy provides a survival benefit for patients with resectable oesophageal cancer who are potentially at increased risk from the adverse effects of radiation. We recently conducted an updated meta-analysis [5] in which we reported that patients with resectable, locally advanced oesophageal squamous cell carcinoma who had neoadjuvant chemoradiotherapy showed a significantly increased survival rate compared to those who had neoadjuvant chemotherapy. In comparison, the survival rate for patients with resectable, locally advanced oesophageal adenocarcinoma did not improve if radiotherapy was combined with neoadjuvant chemotherapy. Further research on this question is badly needed. Therefore, even though we believe that neoadjuvant chemoradiotherapy could increase the survival rate of patients with resectable oesophageal cancer, we feel a controversy still exists as to which neoadjuvant strategy (neoadjuvant chemoradiotherapy, neoadjuvant chemotherapy or even neoadjuavent radiotherapy) represents the optimum preoperative option for patients with resectable locally advanced oesophageal squamous cell carcinoma and adenocarcinoma, respectively, because these two pathological types are different entities.

Conflict of interest: none declared.

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