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Interventions for dysphagia in oesophageal cancer

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Abstract

Background

The majority of oesophageal and gastro‐oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established.

Objectives

To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma.

Search methods

We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re‐run in August 2006 and March 2007.

Selection criteria

Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self‐expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head‐to‐head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30‐day mortality, adverse effects and quality of life.

Data collection and analysis

One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias.

Main results

We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re‐interventions and adverse effects. Anti‐reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti‐reflux stents might reduce gastro‐oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life.

Authors' conclusions

Self‐expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high‐dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self‐expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re‐interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

Interventions for dysphagia in oesophageal cancer

Most patients with oesophageal cancer undergo palliative treatment due to diagnosis at an advanced stage. The optimal palliative technique for dysphagia is not established despite significant progress in endoscopic techniques. The main objective of palliative treatment in patients with inoperable oesophageal or gastro‐oesophageal junctional cancers is to achieve adequate improvement in dysphagia and quality of life, with a reduced need for additional interventions. Insertion of self‐expanding metal stents is safe and provides swift relief of dysphagia. Other techniques, such as external beam radiotherapy or brachytherapy, are suitable alternatives and might provide a better quality of life and prolong survival in these patients. This review has not shown a clear superiority of any of the interventions and emphasises the need to choose carefully from the available interventions to suit the individual patient's requirements.