versión On-line ISSN 2078-5151
S. Afr. j. surg. vol.48 no.2 Cape Town may. 2010
D. LiakosI; D. W. R. DowerII; M. FlorizooneIII; D. B. BizosIV
IM.B. CH.B., B.SC; Department of Surgery, University of the Witwatersrand, Johannesburg
IIM.B. B.CH; Department of Surgery, University of the Witwatersrand, Johannesburg
IIIM.B. B.CH., F.C.S. (S.A.); Department of Surgery, Tshepong Hospital, North West
IVM.B. B.CH., F.C.S. (S.A.), M.MED. (SURG.); Department of Surgery, University of the Witwatersrand
INTRODUCTION: Oesophageal cancer causes much morbidity and mortality in South Africa. Social and economic constraints further impact on the management of these patients. Many prospective randomised trials of palliative treatment have been done in the developed world, not taking into account these socio-economic constraints. We present a study from Tshepong Hospital, a secondary hospital in South Africa, comparing stenting with radiation therapy in the palliative treatment of oesophageal cancer.
PATIENTS AND METHODS: We retrospectively reviewed the data on 30 patients seen between February 2005 and January 2008. All presented with inoperable oesophageal cancer and were palliated with either stenting (N=18) or radiotherapy (N=12). We compared number of admissions, length of hospital stay and time from when first seen to intervention as primary outcomes.
RESULTS: The number of admissions, length of hospital stay and days to procedure were significantly lower in the stent group. No major complications resulting from brachytherapy were reported. Complications in the stent group included chest pain, tumour overgrowth, stent migration and death.
DISCUSSION: Studies have shown the superiority of brachytherapy over stenting with regard to long-term palliation and number of complications. In our setting, however, socioeconomic constraints result in a delay in treatment. Given the short survival expected in these patients, stenting may be a reasonable option to consider given the decreased time to final intervention and hospital stay in patients with a poor prognosis. Adopting a prognostic score can help in identifying these patients.
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The treatment of advanced oesophageal cancer in a resource-constrained clinical setting is difficult and frustrating, and the authors are to be congratulated on documenting their experience. Nevertheless, the conclusion they present is based on a small retrospective series, and this does not trump the evidence of a large prospective randomised trial. I accept that the logistic conditions, nutritional status and even the advanced stage of the cancer (as shown by the larger-bore catheter used by the Dutch investigators compared with what is used in Johannesburg), and our lower mean survivals, are worse in South Africa, but given that intraluminal HDR brachytherapy is available in tertiary hospitals, is relatively complication free, and only incurs additional transport and hospital stay costs, its benefits, namely prolonged dysphagia-free survival (a mean of 7.1 months was reported in the IAEA trial, including South African patients), should not be denied to patients as a matter of course.
I agree with the authors that a prognostic index needs to be developed to determine which patients will benefit from intraluminal brachytherapy. It is important for a South African trial to be set up in this regard, so that the competing modalities of stenting versus HDR brachytherapy can be compared under local conditions, and a locally validated prognostic index can be developed. With regard to delay in implementing treatment, it should be noted that stenting does not preclude subsequent HDR, and early stenting followed by delayed HDR brachytherapy for selected patients needs to be one of the options to consider.
Department of Radiation Oncology Charlotte Maxeke Johannesburg Hospital