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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 1

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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PRISMA flow diagram.
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Figure 2

PRISMA flow diagram.

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Comparison 1 Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone, Outcome 1 Overall survival.
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Analysis 1.1

Comparison 1 Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone, Outcome 1 Overall survival.

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Comparison 1 Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone, Outcome 2 Freedom from locoregional relapse.
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Analysis 1.2

Comparison 1 Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone, Outcome 2 Freedom from locoregional relapse.

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Comparison 1 Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone, Outcome 3 Quality of Life (at 3 months).
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Analysis 1.3

Comparison 1 Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone, Outcome 3 Quality of Life (at 3 months).

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Comparison 1 Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone, Outcome 4 Treatment‐related mortality.
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Analysis 1.4

Comparison 1 Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone, Outcome 4 Treatment‐related mortality.

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Comparison 1 Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone, Outcome 5 Use of salvage procedures for dysphagia.
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Analysis 1.5

Comparison 1 Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone, Outcome 5 Use of salvage procedures for dysphagia.

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Summary of findings for the main comparison. Chemoradiotherapy versus chemoradiotherapy plus surgery for esophageal cancer

Chemoradiotherapy versus chemoradiotherapy plus surgery for esophageal cancer

Patient or population: nonmetastatic esophageal cancer
Setting: hospital
Intervention: chemoradiotherapy plus surgery
Comparison: chemoradiotherapy alone

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect (95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Risk with chemoradiotherapy alone

Risk with chemoradiotherapy plus surgery

Overall survival
Follow‐up: median 4 to 6 years

35.4% to 40.0% at 2 years

34.0% to 39.9% at 2 years

HR 0.99 (95% CI 0.79 to 1.24)

431
(2 RCTs)

⊕⊕⊕⊕
High

Freedom from locoregional relapse

Follow‐up: median 4 to 6 years

40.7% to 57.0% at 2 years

64.3% to 66.4% at 2 years

HR 0.55 (95% CI 0.39 to 0.76)

431
(2 RCTs)

⊕⊕⊕⊝
Moderate1

Quality of Life

assessed with: Spitzer QoL index

Scale: 0 to10

Follow‐up: 3 months

the mean Q0L score was 7.52 points in the chemoradiotherapy alone group

the mean QoL score in the chemoradiotherapy plus surgery group was 0.93 points worse (from ‐1.62 worse to ‐0.24 worse)

165

(1 RCT)

⊕⊝⊝⊝
Very Low2,3,4

Treatment‐related mortality

Follow‐up: median 1 to 3 months

1.9 per 100

9.5 per 100

(3.2 to 27.8)

RR 5.11
(95% CI 1.74 to 15.02)

431
(2 RCTs)

⊕⊕⊝⊝
Low1,2

Use of salvage procedures for dysphagia

Follow‐up: median 4 years

46 per 100

24 per 100

RR 0.52 (95% CI 0.36 to 0.75)

259

(1 RCT)

⊕⊕⊝⊝
Low1,2

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio; HR: Hazard ratio;

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

1 Downgraded one level due to risk of bias (detection bias as investigators were not blinded).
2 Downgraded one level due to imprecision.
3 Downgraded two levels due to risk of bias (detection bias as investigators and participants were not blinded).

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Summary of findings for the main comparison. Chemoradiotherapy versus chemoradiotherapy plus surgery for esophageal cancer
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Comparison 1. Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Overall survival Show forest plot

2

431

Hazard Ratio (Random, 95% CI)

0.99 [0.79, 1.24]

2 Freedom from locoregional relapse Show forest plot

2

431

Hazard Ratio (Random, 95% CI)

0.55 [0.39, 0.76]

3 Quality of Life (at 3 months) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Subtotals only

4 Treatment‐related mortality Show forest plot

2

431

Risk Ratio (M‐H, Random, 95% CI)

5.11 [1.74, 15.02]

5 Use of salvage procedures for dysphagia Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only
Figuras y tablas -
Comparison 1. Chemoradiotherapy (CRT) plus surgery versus chemoradiotherapy alone
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