11New developments in palliative therapy
Section snippets
Palliative treatment to relieve dysphagia
Since most patients with incurable oesophageal cancer live no longer than 6 months, the aim of palliative treatment is rapid relief dysphagia to maintain swallowing during life and to avoid serious complications. Furthermore, it is important to realize that treatment of incurable oesophageal cancer should be individualized and based on tumour stage, medical condition, and performance status of the patient, and the patient's personal wishes. Finally, both the available expertise and the results
Stents
Placement of a stent is nowadays the most frequently used method for palliation of malignant dysphagia. Since 1990, more than 75 studies on the outcome of stent placement for palliation of malignant dysphagia have been published.5, 6, 7
Brachytherapy
Brachytherapy was first used in 1980 as a boost after external-beam radiotherapy for the treatment of oesophageal carcinoma. Patients received 40–50 Gy external-beam radiation followed by 10 Gy brachytherapy given in one or two sessions, starting 2–3 weeks after completion of external-beam radiotherapy. A decade later, brachytherapy as a sole treatment was introduced for the palliation of dysphagia from incurable oesophageal carcinoma. An advantage of brachytherapy in comparison to external-beam
Brachytherapy versus stent placement
Recently, the first randomized trial was published comparing single-dose brachytherapy with metal stent placement for the palliation of dysphagia from incurable oesophageal cancer.52 In total, 209 patients recruited in nine hospitals in the Netherlands were randomized to single-dose (12 Gy) brachytherapy or stent placement (Ultraflex stent). Of these 209 patients, 144 (69%) had an adenocarcinoma, 58 (28%) a squamous-cell carcinoma, and seven (3%) another malignant tumour in the oesophagus.
Prognostic model
On the basis of the findings in the above-mentioned trial52 and additional data on stent placement and brachytherapy from our institution, we developed a prognostic model which could help to identify patients with a poor prognosis in whom stent placement should be at least equivalent to brachytherapy.53 Significant prognostic factors for survival included tumour length, WHO performance score, and the presence of metastases. A simple score was developed which included age (a score varying
Palliative chemotherapy
Patients with incurable disease due to metastasis but in a relatively good general condition (WHO performance score 0–2) are increasingly considered to be candidates for palliative chemotherapy. However, prior to the use of chemotherapy, it is important to first treat dysphagia. This can be done by stent placement, brachytherapy, or placement of a nasoenteric feeding tube. A disadvantage of stent placement prior to chemotherapy is the risk of stent migration into the stomach if a tumour is
Conclusion
The currently available endoscopic treatment modalities for the palliation of malignant dysphagia are, as yet, not optimal in achieving fast and sustained dysphagia relief with minimal morbidity and mortality. Recently, new developments have been introduced that should result in better palliation of patients with incurable oesophageal cancer.
Stents are effective in improving dysphagia; however, the number of reinterventions for recurrent dysphagia is still rather high. The recently introduced
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Cited by (36)
Malignant Bowel Obstruction: Reappraising the Value of Surgery
2018, Surgical Oncology Clinics of North AmericaCitation Excerpt :Esophageal and gastric malignancies may lead to obstruction of the esophagus or gastroesophageal (GE) junction. Such obstructions are rarely complete at the time of presentation and more than 50% of patients with obstructive symptoms have unresectable tumors; many of these patients require palliative intervention.36–38 Stent placement can provide immediate relief of dysphagia and is the most commonly used palliative treatment option for patients with dysphagia and unresectable esophageal and GE junction tumors.36,39–42
Nurse-led follow-up at home vs. conventional medical outpatient clinic follow-up in patients with incurable upper gastrointestinal cancer: A randomized study
2014, Journal of Pain and Symptom ManagementCitation Excerpt :Symptoms of upper gastrointestinal (GI) cancer tend to appear at a relatively late stage of the disease.1–3
Palliative radiotherapy in patients with esophageal carcinoma: A retrospective review
2012, Practical Radiation OncologyRecordings of consultations are beneficial in the transition from curative to palliative cancer care: A pilot-study in patients with oesophageal or head and neck cancer
2012, European Journal of Oncology NursingCitation Excerpt :These patients showed less improvement in psychological well-being during follow-up than controls without a recording, probably because the detailed information had a negative impact on the process of adaptive denial (McHugh et al., 1995). Patients diagnosed with oesophageal or head and neck cancer often present with debilitating symptoms from advanced disease and a poor prognosis (Siersema, 2006; Ledeboer et al., in press). Furthermore, these cancer types have been found to correlate with socio-economic deprivation (Islami et al., 2009; Robertson et al., 2010).
Esophageal strictures, tumors, and fistulae: Stents for primary esophageal cancer
2010, Techniques in Gastrointestinal EndoscopyA fully-covered stent (Alimaxx-E) for the palliation of malignant dysphagia: a prospective follow-up study
2009, Gastrointestinal EndoscopyCitation Excerpt :Stent migration was only associated with tumor histology, particularly adenocarcinoma, but not with other tumor- or stent-related factors in univariate analysis (Table 4). Nevertheless, because all adenocarcinomas were located in the distal esophagus, tumor location probably played a role in the high migration rate.13,14 This may also explain why the migration rate was higher, although not significantly, with large-diameter stents compared with small-diameter stents.