In contrast to the incidence of gastric cancer, which has fallen worldwide, the incidence of esophageal cancer has been increasing at an appreciable rate. There has been an increase in the incidence of adenocarcinoma of the distal esophagus, together with a shift of gastric carcinoma from the distal part of the stomach to the cardia and esophago-gastric junction [1-4]. Surgical resection is still the treatment for esophageal carcinoma which gives the best chance of achieving a cure, but this can only be achieved by accurate staging of the disease and may be improved by neo-adjuvant or adjuvant chemo-radiotherapy [2, 3]. The majority of patients diagnosed with upper gastrointestinal cancer only survive a few months after diagnosis because of the insidious nature of the condition but this poor prognosis is not fully reflected in published series of cases referred for surgery. The relatively low incidence of the disease in the UK may also delay presentation and result in the disease being too advanced at presentation for surgical intervention. There was an apparent change in the management of esophageal carcinoma with a more selective approach to surgical resection and an increase in palliation by intubation and radiotherapy in the era before the introduction of modern multidisciplinary management

[5] with intensive staging investigations and the increasing use of chemotherapy. However the evidence for such a trend has been anecdotal and any change in practice and outcome has not been well documented. A ten year cohort study spanning the period of the perceived change of management, 1985-1994, was therefore carried out. The inclusion of all cases of esophageal cancer in a defined population documents the overall survival from the disease in the era preceding current multidisciplinary management.

Over a ten year period between 1985-1994, all cases of esophageal carcinoma were studied in a Health District with a stable population of approximately 280,000. All death certificates over the period were examined and a computer search of the histopathological data-base was carried out for all cancers of the esophagus and stomach. A hand search was made of the operating theatre logbooks and a hand/computer search of the endoscopy records was also performed. Where possible the hospital records were retrieved and those cases of documented carcinoma of the cardia were included. Details of the histological type and node status were recorded. Cases with carcinoma of the body and distal stomach were excluded.

Details of the type of stent inserted and whether the latter was used in conjunction with chemo- or radiotherapy were recorded. The type of surgical resection and the operating surgeon were recorded. Data on the trends in the catchment population over the period of the study were obtained from the Office for National Statistics [6]. The treatment year and the length of survival were taken from the date of diagnosis. Operative mortality at 30 days was taken from the date of operation. All patients were followed up and at the most recent review of the survivors in October 2005, the minimum length of follow-up was 11 years. Overall and recurrence-free survival following primary treatment with surgery, radiotherapy alone, dilatation/intubation alone or supportive care were compared by Life Table analysis (Kaplan-Meier) and statistical analysis by the log rank test (Medcalc Schoonjans 2005).

A total of 413 patients diagnosed with esophageal carcinoma was identified between 1985 and 1994 of whom 109 had a surgical resection. From 1992 onwards there was a sharp decline in the proportion of patients treated by surgery, (Fig. 1) although the number of cases increased (Table 1). In the last 2 years of the study only 9 of 84 (11%) patients with esophageal cancer had a surgical resection.

Table 1

Treatments Received by all Patients by Year 1985-1994: Treatment given to Total Cohort

There was a corresponding rise in the proportion of patients treated conservatively from 63% up to the end of 1988, to 79% in the subsequent years. The proportion of patients who received radiotherapy with palliative intent (n=92), or in addition to surgery (n=14) also rose over the 10 year period (Fig. 1).

Fig. (1) Treatment of patients with esophageal cancer by surgery and radiotherapy over the decade 1985-1994.

Dilatation of esophageal cancers with or without intubation was carried out in 234 patients (Table 1) and in 103 cases this was the sole primary treatment. Palliation with a stent was attempted in 93 patients of which 73% were of Celestin type, 22% Nottingham/Atkinson and 5% were not recorded. No patient in this cohort received intubation with an expandable metal stent.

Chemotherapy was only given to 13 patients which was adjuvant to other treatment in 9 patients but in 4 was the sole primary treatment.

No active primary treatment was given to 105 patients (25%) who received supportive care. This group included 12 patients where the diagnosis was only confirmed at post mortem and 37 patients where the diagnosis was confirmed but no definitive treatment was given.

Of the 109 patients treated by surgical resection, under the care of four surgeons, 59% underwent transhiatal esophagectomy, 16% an Ivor-Lewis operation, 12% a left thoracic approach, 7% a transabdominal operation for carcinoma of the cardia and in 4% a 3 stage procedure was carried out. In 3 cases the operation record was not available. Adjuvant radiotherapy was given in 14 surgical cases and chemotherapy in 5.

Histological confirmation was confirmed in 93% of cases. In the first two years 1985-1986 the incidence of adenocarcinoma (47%) was similar to squamous cell carcinoma but thereafter adenocarcinoma became predominant (70%).

CT scans were not available until the last three years of the study but pre-operative staging by laparoscopy was used to an increasing extent in the later years.

The office for National Statistics estimated the rise in the catchment population for S.E. Kent over the study period in the age range 70-74 to have been 7% in males and 4.8 % in females [6]. It is unlikely that many patients were referred outside the district for the treatment of esophageal cancer over the period of the study. Only one patient is known to have been referred for resectional surgery in London.

The very few long-term survivors in this total population cohort of patients from the decade 1985-1994 had all been treated by surgery alone. The increasing place of chemotherapy in the treatment of esophageal cancer had not yet been established but his study does document a change in practice towards a more selective management of esophageal cancer with a decline in the rate of surgical resection. The outlook for those patients offered surgery improved and it is likely that the reduction of operative mortality from 12% to 6.9% is largely due to improved intensive care facilities. However, the separation of the survival curves at about 1 year in Fig. (5), in the absence of adjuvant therapy in the long-term survivors suggests that case selection may have improved. CT scans were only available from 1992 and pre-operative staging by laparoscopy was used to an increasing extent in the latter part of the study. It is likely that these two factors largely account for the reduced number of patients offered surgery towards the end of the period (Fig. 1). Every effort was made to identify all cases of esophageal cancer in the defined population cohort and although it is possible that more patients were referred to specialist centers this was not common practice over this period and any such case is likely to have been identified by the pre-operative biopsy or the death certificate. The few cases diagnosed at post mortem, where this was the certified cause of death, are unlikely to have died from another cause.