Introduction: The CROSS group published data supporting the use of neoadjuvant chemoradiotherapy for oesophageal cancer in 2012, demonstrating good efficacy with an observed complete pathological response rate of 29% in surgical specimens. Given that this regimen has little toxicity and was generally well tolerated, we investigated the feasibility of integrating this regimen to the radical setting in patients who were of borderline fitness to receive radical chemo-radiotherapy with cisplatin.
Methods: From 2013-2015, 9 patients at our centre received CROSS-style chemoradiotherapy (CRT) with weekly carboplatin/paclitaxel. We compared their outcome to 29 patients who received the Herscovic CRT regime with cisplatin/5FU at D1 and D29 during that time frame. A total radiation dose of 50.4Gy in 28 fractions of 1.8Gy each, 5 fractions per week was administered.
Results: Median age in the CROSS group was 58 (range 51-76) and 66 (range 46-83) in the Herscovic group. Neoadjuvant chemotherapy was given to 89% of CROSS patients and 41% of Herscovic patients. All CROSS patients completed radiotherapy treatment and no radiotherapy breaks were required. In the Herscovic group, 20.7% of patients did not complete radiotherapy and 34.5% had a break in their radiotherapy treatment. Chemotherapy was discontinued in 33.3% CROSS vs 37.9% Herscovic and dose reduced in 0% CROSS vs 31% Herscovic. Three patients (10%) died during Herscovic treatment. Rate of acute hospital admission related to early toxicity was 22% in CROSS vs 37.9% in Herscovic patients. The radiological response rate at 12 weeks post treatment was 80% in the CROSS group (50% scanned) and 76.2% in the Herscovic group (72% scanned).
Conclusion: CROSS-style schedule as a primary CRT regimen is effective and safe with lesser morbidity and mortality than traditional Herscovic CRT regimen. It is also more cost-effective and convenient for patients as it is administered in the outpatient setting compared to the Herscovic schedule, which requires a total inpatient stay of 10 days during treatment. Longer follow up and a randomised clinical trial is warranted to fully establish the clinical effectiveness of this schedule as a primary radical treatment.