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Meta-Analysis
. 2013 May 31;2013(5):CD008107.
doi: 10.1002/14651858.CD008107.pub2.

Perioperative chemo(radio)therapy versus primary surgery for resectable adenocarcinoma of the stomach, gastroesophageal junction, and lower esophagus

Ulrich Ronellenfitsch  1 , Matthias Schwarzbach, Ralf Hofheinz, Peter Kienle, Meinhard Kieser, Tracy E Slanger, Katrin Jensen; GE Adenocarcinoma Meta‐analysis Group
Affiliations
Meta-Analysis

Perioperative chemo(radio)therapy versus primary surgery for resectable adenocarcinoma of the stomach, gastroesophageal junction, and lower esophagus

Ulrich Ronellenfitsch et al. Cochrane Database Syst Rev. .

Abstract

Background: The outcome of patients with locally advanced gastroesophageal adenocarcinoma (adenocarcinoma of the esophagus, gastroesophageal (GE) junction, and stomach) is poor. There is conflicting evidence regarding the effects of perioperative chemotherapy on survival and other outcomes.

Objectives: To assess the effect of perioperative chemotherapy for gastroesophageal adenocarcinoma on survival and other clinically relevant outcomes in the overall population of participants in randomized controlled trials (RCTs) and in prespecified subgroups.

Search methods: We performed computerized searches in the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Review of Effectiveness (DARE), the Cochrane Database of Systematic Reviews (CDSR) from The Cochrane Library, MEDLINE (1966 to May 2011), EMBASE (1980 to May 2011), and LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud), combining the Cochrane highly sensitive search strategy with specific search terms. Moreover, we handsearched several online databases, conference proceedings, and reference lists of retrieved papers.

Selection criteria: We included RCTs which randomized patients with gastroesophageal adenocarcinoma, in the absence of distant metastases, to receive either chemotherapy with or without radiotherapy followed by surgery, or surgery alone.

Data collection and analysis: Two independent review authors identified eligible trials. We solicited individual patient data (IPD) from all selected trials. We performed meta-analyses based on intention-to-treat populations using the two-stage method to combine IPD with aggregate data from RCTs for which IPD were unavailable. We combined data from all trials providing IPD in a Cox proportional hazards model to assess the effect of several covariables on overall survival.

Main results: We identified 14 RCTs with 2422 eligible patients. For eight RCTs with 1049 patients (43.3%), we were able to obtain IPD. Perioperative chemotherapy was associated with significantly longer overall survival (hazard ratio (HR) 0.81; 95% confidence interval (CI) 0.73 to 0.89). This corresponds to a relative survival increase of 19% or an absolute survival increase of 9% at five years. This survival advantage was consistent across most subgroups. There was a trend towards a more pronounced treatment effect for tumors of the GE junction compared to other sites, and for combined chemoradiotherapy as compared to chemotherapy in tumors of the esophagus and GE junction. Resection with negative margins was a strong predictor of survival. Multivariable analysis showed that tumor site, performance status, and age have an independent significant effect on survival. Moreover, there was a significant interaction of the effect of perioperative chemotherapy with age (larger treatment effect in younger patients). Perioperative chemotherapy also showed a significant effect on several secondary outcomes. It was associated with longer disease-free survival, higher rates of R0 resection, and more favorable tumor stage upon resection, while there was no association with perioperative morbidity and mortality.

Authors' conclusions: Perioperative chemotherapy for resectable gastroesophageal adenocarcinoma increases survival compared to surgery alone. It should thus be offered to all eligible patients. There is a trend to a larger survival advantage for tumors of the GE junction as compared to other sites and for chemoradiotherapy as compared to chemotherapy in esophageal and GE junction tumors. Likewise, there is an interaction between age and treatment effect, with younger patients having a larger survival advantage, and no survival advantage for elderly patients.

PubMed Disclaimer

Conflict of interest statement

RH has participated in several trials assessing the effect of various chemotherapeutic agents on upper GI tract cancer.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' summary: review authors' judgments about each risk of bias item for each included study.
3
3
'Risk of bias' graph: review authors' judgments about each risk of bias item presented as percentages across all included studies.
4
4
Funnel plot of comparison: 1 Overall survival, outcome: 1.1 Hazard ratio plot for overall survival.
5
5
Simple (non‐stratified) overall survival curves of perioperative chemotherapy plus surgery versus surgery alone (perioperative chemo: 372 events, 525 total; surgery alone: 405 events, 524 total; hazard ratio 0.80, 95% CI 0.69 to 0.93).
6
6
Overall survival curves by type of resection: 719 patients with R0, R1 or R2, 99 patients not resected or missing (R0: 390 events, 611 total; R1: 43 events, 46 total; R2: 60 events, 62 total).
7
7
Hazard ratio with 95% confidence interval for perioperative chemo(radio)therapy versus surgery alone for age in 5‐year increments.
8
8
Funnel plot of comparison: 2 Disease‐free survival (landmark time 6 months), outcome: 2.1 Hazard ratio plot for disease‐free survival (landmark time 6 months).
9
9
Funnel plot of comparison: 3 Presence of tumor‐free resection margin, outcome: 3.1 Odds ratio plot for tumor‐free resection margin.
10
10
Funnel plot of comparison: 4 Tumor stage at resection, outcome: 4.1 Odds ratio plot for tumor stage T0/T1/T2.
11
11
Funnel plot of comparison: 4 Tumor stage at resection, outcome: 4.2 Odds ratio plot for nodal status N0.
12
12
Funnel plot of comparison: 6 Postoperative morbidity, outcome: 6.1 Risk difference plot for postoperative morbidity.
13
13
Funnel plot of comparison: 7 Postoperative mortality, outcome: 7.1 Risk difference plot for postoperative mortality.
1.1
1.1. Analysis
Comparison 1 Overall survival, Outcome 1 Hazard ratio plot for overall survival.
1.2
1.2. Analysis
Comparison 1 Overall survival, Outcome 2 Hazard ratio plot for overall survival by type of data.
1.3
1.3. Analysis
Comparison 1 Overall survival, Outcome 3 Hazard ratio plot for overall survival by tumor site.
1.4
1.4. Analysis
Comparison 1 Overall survival, Outcome 4 Interaction treatment‐tumor site (only IPD).
1.5
1.5. Analysis
Comparison 1 Overall survival, Outcome 5 Hazard ratio plot for overall survival by chemo‐/radiotherapy.
1.6
1.6. Analysis
Comparison 1 Overall survival, Outcome 6 Hazard ratio plot for overall survival by timing of regimen.
1.7
1.7. Analysis
Comparison 1 Overall survival, Outcome 7 Hazard ratio plot for overall survival by chemotherapeutic agents.
1.8
1.8. Analysis
Comparison 1 Overall survival, Outcome 8 Hazard ratio plot for overall survival by performance status (only IPD).
1.9
1.9. Analysis
Comparison 1 Overall survival, Outcome 9 Interaction treatment‐performance status (only IPD).
1.10
1.10. Analysis
Comparison 1 Overall survival, Outcome 10 Hazard ratio plot for overall survival by age (only IPD).
1.11
1.11. Analysis
Comparison 1 Overall survival, Outcome 11 Interaction treatment‐age (only IPD).
1.12
1.12. Analysis
Comparison 1 Overall survival, Outcome 12 Hazard ratio plot for overall survival by sex (only IPD).
1.13
1.13. Analysis
Comparison 1 Overall survival, Outcome 13 Interaction treatment‐sex (only IPD).
1.14
1.14. Analysis
Comparison 1 Overall survival, Outcome 14 Hazard ratio plot for overall survival by pretreatment T class (only IPD).
1.15
1.15. Analysis
Comparison 1 Overall survival, Outcome 15 Interaction treatment‐T class (only IPD).
1.16
1.16. Analysis
Comparison 1 Overall survival, Outcome 16 Hazard ratio plot for overall survival by pretreatment N class (only IPD).
1.17
1.17. Analysis
Comparison 1 Overall survival, Outcome 17 Interaction treatment‐N class (only IPD).
2.1
2.1. Analysis
Comparison 2 Disease‐free survival (landmark time 6 months), Outcome 1 Hazard ratio plot for disease‐free survival (landmark time 6 months).
3.1
3.1. Analysis
Comparison 3 Presence of tumor‐free resection margin, Outcome 1 Odds ratio plot for tumor‐free resection margin.
4.1
4.1. Analysis
Comparison 4 Tumor stage at resection, Outcome 1 Odds ratio plot for tumor stage T0/T1/T2.
4.2
4.2. Analysis
Comparison 4 Tumor stage at resection, Outcome 2 Odds ratio plot for nodal status N0.
6.1
6.1. Analysis
Comparison 6 Postoperative morbidity, Outcome 1 Risk difference plot for postoperative morbidity.
7.1
7.1. Analysis
Comparison 7 Postoperative mortality, Outcome 1 Risk difference plot for postoperative mortality.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD008107

References

References to studies included in this review

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