Diseases of the Esophagus (2006) 19, 164 –171

© 2006 ISDE

Original article
Blackwell Publishing Asia

Multidisciplinary team management is associated with improved outcomes

after surgery for esophageal cancer

M. R. Stephens,1 W. G. Lewis,3 A. E. Brewster,2 I. Lord,1 G. R. J. C. Blackshaw,1 I. Hodzovic,1 G. V. Thomas,1

S. A. Roberts,3 T. D. L. Crosby,2 C. Gent,1 M. C. Allison,1 K. Shute1

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1
Gwent Healthcare NHS Trust, Royal Gwent Hospital, Newport, 2Velindre NHS Trust, Cardiff, and 3Cardiff and
Vale NHS Trust, University Hospital of Wales, Cardiff, Wales, UK (On behalf of the South East Wales Upper
Gastrointestinal Cancer Network)

SUMMARY. We aim to compare the outcomes of patients undergoing R0 esophagectomy by a multidiscipli-

nary team (MDT) with outcomes after surgery alone performed by surgeons working independently in a UK
cancer unit. An historical control group of 77 consecutive patients diagnosed with esophageal cancer and
undergoing surgery with curative intent by six general surgeons between 1991 and 1997 (54 R0 esophagecto-
mies) were compared with a group of 67 consecutive patients managed by the MDT between 1998 and 2003
(53 R0 esophagectomies, 26 patients received multimodal therapy). The proportion of patients undergoing open
and closed laparotomy and thoracotomy decreased from 21% and 5%, respectively, in control patients, to 13%
and 0% in MDT patients (χ χ2 = 11.90, DF = 1, P = 0.001; χ2 = 5.45, DF = 1, P = 0.02 respectively). MDT
patients had lower operative mortality (5.7% vs. 26%; χ2 = 8.22, DF = 1, P = 0.004) than control patients, and
were more likely to survive 5 years (52% vs. 10%, χ2 = 15.05, P = 0.0001). In a multivariate analysis, MDT
management (HR = 0.337, 95% CI = 0.201–0.564, P < 0.001), lymph node metastases (HR = 1.728, 95%
CI = 1.070–2.792, P = 0.025), and American Society of Anesthesiologists grade (HR = 2.207, 95%
CI = 1.412–3.450, P = 0.001) were independently associated with duration of survival. Multidisciplinary team
management and surgical subspecialization improved outcomes after surgery significantly for patients diag-
nosed with esophageal cancer.
KEY WORDS: esophageal cancer, multidisciplinary teams, surgery.

INTRODUCTION between 1953 and 1979.2 This suggested that of

Cancer of the esophagus is now the ninth most
common cancer worldwide, accounting for 7000
new diagnoses and 6700 deaths per year in the UK
alone.1 Despite sporadic reports to the contrary the
overall outlook for patients diagnosed with this
tumor remains bleak and there remains a prevailing
pessimism among clinicians regarding the treatment
and prognosis of patients with cancer of the
esophagus.
Much of this nihilistic attitude originated from a
critical surgical review conducted over 20 years ago
of 84 000 patients who had received treatment
Address correspondence to: Wyn G. Lewis MD FRCS,
Consultant Surgeon, Department of Surgery, University
Hospital of Wales, Heath Park, Cardiff, United Kingdom, CF14
4XW. Email: wyn.lewis@cardiffandvale.wales.nhs.uk
164 Journal compilation © 2006 The International Society for Diseases of the Esophagus
every 100 patients with esophageal cancer, only 39
would have their tumors resected, of whom 26
would leave hospital, and only four would survive
5 years. Despite many advances in preoperative
radiological staging, improved anesthetic technique
and more radical surgical procedures over the next
10 years, a report from Leeds in 1994 encompassing
the years 1975–1994 showed no improvement.3
Moreover, the recent regional audit of the manage-
ment of esophagogastric cancer in Wales demon-
strated that many individual surgeons’ caseloads
remained small, staging strategies were idiosyn-
cratic, and open and closed operations were per-
formed in as many as 23% of cases.4
Findings such as these have led to the guidance
on commissioning cancer services.5 These guidelines
stipulate that specialist teams should be established
at appropriate cancer centers or units, and that
© 2006 The Authors
 Multidisciplinary team esophagectomy 165

these should draw patients from populations of Table 1 Details of the patients who underwent R0 esophagectomy
more than one million.
Control MDT
The aim of this study was to compare the out-
comes of patients undergoing R0 esophagectomy Number 54 53
by one consultant anesthetist and two specialist Median age in years (range) 61 (38 –76) 60 (38 –78)
Sex m:f 35 : 19 35 : 18
surgeons, working as part of a multidisciplinary Histopathological cell type
team (offering specialist radiological, and anesthetic Adenocarcinoma 40 38
support, and neoadjuvant chemoradiotherapy where Squamus cell carcinoma 14 15
Histopathological stage of cancer
indicated) with outcomes after surgery alone per- I 2 (4) 2 (4)
formed by six general surgeons working independ- II 11 (20) 11 (21)
ently in a large UK cancer unit serving a III 41 (76) 37 (70)
Path. CR 0 3 (6)
population of 560 000. ASA Grade
I 4 (7) 3 (6)
II 36 (67) 25 (47)

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III 14 (26) 25 (47)*
PATIENTS AND METHODS
Figures are numbers of patients (per cent in parentheses); MDT,
Two groups of patients were studied. Between multidisciplinary team; ASA, American Society of
Anesthesiologists; Path. CR, complete pathological response to
January 1, 1991 and December 31, 1997 342 con- neoadjuvant chemoradiotherapy *χ2 = 5.211, DF = 1, P = 0.022
secutive patients with esophageal carcinoma were
diagnosed at the Royal Gwent Hospital, Wales. Table 2 Operative procedures used in 107 R0 esophagectomies
Clinical and pathological information on this group related to multidisciplinary team (MDT) management
of patients between January 1, 1991 and Septem-
ber 30, 1995 was obtained by retrospective review Control MDT
of patients’ case notes and was obtained prospect- Laparotomy, right thoracotomy 51 16
ively from October 1, 1995 until December 31, Laparotomy, right thoracotomy, 1 1
1997. Seventy-seven of these patients (median age cervical anastomosis
Transhiatal esophagectomy 2 36
60 years, 50 male) underwent surgery with curative Pyloroplasty 35 0
intent by six consultant general surgeons and poten- Pyloromyotomy 0 1
tially curative resection was possible in 54 (70%) Pylorus left intact 19 52
Anastomosis hand sewn 37 53
patients. This comprises our historical control Anastomosis stapled 17 0
group. Between January 1, 1998 and December 31,
2003 185 patients out of a total of 303 patients
(61%) diagnosed with esophageal cancer were using a multislice Toshiba Aquilon volume
referred to and treated by a multidisciplinary team acquisition spiral CT system. EUS was performed
(MDT) comprising two consultant surgeons (WGL using an MH-908 esophagoprobe.
and KS, who operated together as a team), two The definition of a potentially curative resection
radiologists, one oncologist, two gastroenterolo- was that all visible tumor was removed and that
gists, one anesthetist, one pathologist, and one spe- both proximal and distal resection margins were
cialist nurse. Sixty-seven of these patients (median free of tumor on histological examination. Involve-
age 61 years, 47 male) underwent anesthesia and ment of the circumferential resection margin
surgery with curative intent by one consultant (CRM) was defined as the presence of tumor less
anesthetist and the two MDT consultant surgeons. than 1 mm from the circumferential margin.
Potentially curative resection was possible in 53
(79%) patients. This comprises our MDT group.
Surgical treatment
The demographic details of the patients undergoing
R0 esophagectomy are shown in Table 1. Preoper- The details of the surgery performed are shown in
ative staging was done with the aid of computer- Table 2. Transhiatal resection was performed for
ized tomography (CT), endoluminal ultrasound patients with tumors of the lower third of the
(EUS, after October 1, 1995) and laparoscopy if esophagus deemed to be T1-2 N0 on staging, or if
considered appropriate (tumors of perceived pre- the patient was assessed as American Society of
operative stage of T3 N1 MX of the lower third of Anesthesiologists (ASA) grade III. All tumors were
the esophagus). The CT examinations undertaken staged in accordance with the TNM Classification
before June 23, 1997 were performed using an of Malignant Tumors.6,7
incremental General Electric CT scan system.
Between June 23, 1997 and April 10, 2002 the CT
Neoadjuvant treatment
examinations were performed using a helical
Siemens Somatom +4 CT system; and after April Following the inception of the MDT, all patients
10, 2002 the CT examinations were performed with a diagnosis of esophageal cancer were discussed
© 2006 The Authors
Journal compilation © 2006 The International Society for Diseases of the Esophagus
166 Diseases of the Esophagus

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Fig. 1 Flow diagram showing the Multidisciplinary Team treatment algorithm for patients with potentially curable oesophageal
cancer. CRT = Chemoradiotherapy; ECX = epirubicin cisplatin capecitabine.

weekly, and treatment strategies were developed
and tailored for individual patients based on the
treatment algorithm shown in Fig. 1. Patients with
a perceived preoperative stage of T3 NX M0 and
ASA grades I–III were considered for multi
modality treatment. Twenty-six patients managed
by the MDT received multimodal therapy. Patients
treated prior to 2002 were offered chemoradio-
therapy as the neoadjuvant treatment of choice, but
this policy was changed following the publication
of the results of the large UK randomized trial of
neoadjuvant chemotherapy (OE02). Patients were
subsequently offered neoadjuvant chemotherapy
alone. Thirteen patients received neoadjuvant chemo-
therapy (median age 58 years [47–70], 11 male) and
13 received chemoradiotherapy (56 years [38–76], 7
male). Neoadjuvant chemotherapy consisted of two
cycles of cisplatin (80 mg/m2) and 5FU for 4 days.
Neoadjuvant chemoradiotherapy consisted of 2
cycles of cisplatin (60 mg/m2) with 225 mg/m2 per
Journal compilation © 2006 The International Society for Diseases of the Esophagus
day of infusional 5FU prior to 45 Gy in 25
Fractions in 5 weeks concurrent with 3-weekly
cisplatin (60 mg/m2) and infusional 5FU (200 mg/
m2/day). Radiotherapy was administered with a
two-phase technique starting with parallel-opposed
fields followed by a three field 3-dimensional plan.
Follow up
Patients undergoing esophagectomy were reviewed
every 3 months for the first year and every
6 months thereafter. All of the control patients
were followed up for at least 5 years or until death.
The median duration of follow-up for MDT
patients was 31 months (5–65), and 30 patients
(57%) were followed up for at least 5 years or until
death. Endoscopy and computed tomography were
arranged if recurrent disease was suspected. Causes
of death were sought from case notes, pathology
records, and general practitioners’ records.
© 2006 The Authors
 Multidisciplinary team esophagectomy 167

Statistical analysis Table 3 Details of the management of 645 consecutive patients

diagnosed with esophageal cancer
Statistical analysis appropriate for non-parametric 1991–1997 1998–2003
data was used. Grouped data were expressed as
median (range). Grouped data was compared using Total number of patients 342 303
Referred to multidisciplinary team 0 183 (60)
the Mann–Whitney U-test for unpaired data.8 Number of patients undergoing 77 (23%) 67 (22)
Cumulative survival was calculated by the life table surgery with curative intent
method of Kaplan and Meier.9 Differences in R0 esophagectomy 54 (16) 53 (17)
Radical radiotherapy 2 (0.5) 15 (5)*
survival times between groups of patients were Palliative chemo/radiotherapy 8 (2) 55 (18)**
analysed by the log rank method. Cox’s propor- Esophageal stent 72 (21) 51 (17)
tional hazards model was used to assess the prog- Palliative care only 183 (54) 115 (38)**
nostic value of individual variables. Data analysis *P = 0.001, **P < 0.001. Figures are numbers of patients (per
was carried out with the Statistical Package for cent in parentheses)
Social Sciences (SPSS) version 12 (SPSS, Chicago,

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Illinois, USA).
(χ2 = 5.45, DF = 1, P = 0.02), and 5 (7%) under-
went palliative esophagectomy (four patients
RESULTS CRM+, one patient was subsequently proven to
have a liver metastasis).
Patterns of referral of patients diagnosed with
esophageal cancer
Chemotherapy associated morbidity and mortality
Between January 1, 1991 and September 30, 1995
we have no data for the total number of patients One patient undergoing neoadjuvant chemoradio-
referred for a surgical opinion, but a median of therapy developed grade III toxicity in the form of
seven (3–13) R0 esophagectomies were performed life-threatening sepsis, and one patient undergoing
each year. Between 1996 and 2003, the number of neoadjuvant chemotherapy developed significant
patients referred per year for a surgical opinion neutropenia.
increased from 11 (23%) patients in 1996 to 44 (76%)
patients in 2003 (χ2 = 32.13, DF = 1, P < 0.001).
Operative morbidity and mortality
The details of the major operative morbidity and
Preoperative staging
mortality are shown in Table 4. Of the three MDT
All of the patients managed by the MDT under- patients who suffered fatal complications, two had
went a preoperative CT scan compared with 29 received neoadjuvant chemoradiotherapy and both
(54%) of the control patients (χ2 = 30.02, DF = 1, died of acute respiratory distress syndrome
P < 0.001). All of the patients deemed potential (ARDS).
surgical candidates by the MDT also underwent a
preoperative EUS compared with five (9%) of the
Details of pathological response to neoadjuvant
control patients (χ2 = 91.12, DF = 1, P < 0.001).
therapy
Of the patients who received neoadjuvant therapy,
Details of global treatment modalities utilized
based on TNM criteria, 14 patients had no
Table 3 documents the different types of treatment
modalities utilized for all of the patients in the
study. Of the 77 patients who underwent surgery Table 4 Details of the operative morbidity and mortality
with curative intent, 54 patients (70%) underwent a
potentially curative R0 esophagectomy, 16 (21%) Control MDT
underwent open and close laparotomy, six (8%) Anastomotic leak 7 (5) 1
underwent open and closed thoracotomy, and four Respiratory infection 16 (5) 9 (2)
(5%) underwent palliative esophagectomy (three Thromboembolic 3 (2) 1 (1)
Arrhythmia 2 0
patients CRM+ [cross-reacting material positive], Myocardial infarction 1 (1) 1
one patient was subsequently proven to have a liver Jejunostomy volvulus 1 (1) 1
metastasis). Of the 67 MDT patients who Chylothorax 1 1
Hemorrhage 0 1
underwent surgery with curative intent, 53 patients Wound infection 2 1
(79%) underwent a potentially curative R0 esoph- Total percent 61 (26) 30* (5.7**)
agectomy, nine (13%) underwent open and close
Figures are numbers of patients; operative deaths are in
laparotomy (χ2 = 11.90, DF = 1, P = 0.001), no parentheses; MDT, multidisciplinary team; *χ2 = 10.97, DF = 1,
patients underwent open and close thoracotomy P = 0.001; **χ2 = 8.22, DF = 1, P = 0.004
© 2006 The Authors
Journal compilation © 2006 The International Society for Diseases of the Esophagus
168 Diseases of the Esophagus

response (eight chemotherapy, six chemoradio-

therapy) and nine patients a partial response (five
chemotherapy, four chemoradiotherapy). All of the
three patients deemed to have had a complete
pathological response had received neoadjuvant
chemoradiotherapy.

Survival
Corrected cumulative survival by treatment, cal-
culated by life table analysis, is shown in Fig. 2.
The cumulative 5-year survival following R0
esophagectomy for the control patients was 10%
compared with 52% in the MDT patients

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(χ2 = 15.05, DF = 1, P = 0.0001). The median
survival following R0 esophagectomy in control
patients was 18 months (95% CI = 10–26)
compared with 66 months (15–116) in MDT
patients. The cumulative survival related to the type
of neoadjuvant therapy is shown in Fig. 3. The
factors found to be significantly associated with the
duration of survival on univariate analysis are
shown in Table 5. The hazard function related to
MDT treatment or not, is shown in Fig. 4.
Outcomes related to individual consultant surgeon’s
teams
The details of the individual consultant’s surgical
workload and outcomes are shown in Table 6.
There was no statistical correlation between con-
sultant surgeon’s individual workloads and patients’
1- and 5-year survival (Spearman’s correlation
coefficients 0.324 and 0.243, P = 0.478 and
P = 0.599 respectively).
Fig. 3 Cumulative survival after R0 esophagectomy related
to type of neoadjuvant therapy. Log rank 7.74, DF = 2,
P = 0.0209. Operative deaths were excluded. Number at risk
in parenthesis. – – – – – – Neoadjuvant chemoradiotherapy;
- - - - - - - Neoadjuvant chemotherapy; __________ Surgery
alone.
Multivariate analysis
The prognostic variables entered into the model
were ASA grade, neoadjuvant chemoradiotherapy,
extent of lymphadenectomy, neoadjuvant treat-
ment, lymph node involvement, MDT manage-
ment, anesthetist, type of operation and operating
surgeon. Forward and backward stepwise regres-
sion was used. MDT management (HR = 0.337,
95% CI = 0.201–0.564, P < 0.001), lymph node
metastases (HR = 1.728, 95% CI = 1.070–2.792,
P = 0.025), and ASA grade (HR = 2.207, 95%
CI = 1.412–3.450, P = 0.001) were found to be

Table 5 Univariate analysis of factors associated with

durations of survival

Factor Log rank P-value

BMI 0.15 0.6974

Histopathological cell type 1.16 0.5592
Splenectomy 0.37 0.5414
Overall stage 2.47 0.4804
T stage 6.66 0.1551
Gender 2.04 0.1536
Age 43.01 0.0740
Neoadjuvant chemotherapy 3.84 0.0501
Neoadjuvant chemoradiotherapy 4.02 0.0450
N stage 4.81 0.0282
Operation type 8.05 0.0178
ASA 8.49 0.0143
Lymphadenectomy 6.14 0.0132
Neoadjuvant treatment 9.16 0.0025
MDT treatment 15.05 0.0001
Fig. 2 Cumulative survival after R0 esophagectomy related Anesthetist 26.47 0.0001
to multidisciplinary team (MDT) management. Log rank Surgeon 28.28 0.0001
8.46, DF = 1, P = 0.0036. Operative deaths were excluded.
Number at risk in parenthesis. ———— MDT; ASA, American Society of Anesthesiologists; MDT,
- - - - - - Control. multidisciplinary team.
© 2006 The Authors
Journal compilation © 2006 The International Society for Diseases of the Esophagus

Fig. 4 Cumulative hazard function related to multidisciplinary
team management (MDT) treatment. ———— MDT;
- - - - - - - Control.
the most important predictors of survival as
determined by Cox’s proportional hazards model
(global χ2 for the model was 28.405, DF = 3,
P < 0.001).
DISCUSSION
The principal finding of this study was that the key
recommendations of the Clinical Outcomes Group
(COG) guidelines regarding specialist services and
multiprofessional teams were implemented in a
large UK district general hospital and were
associated with improved outcomes after surgery
for patients with esophageal carcinoma. The
proportion of patients undergoing optimal staging
investigations increased significantly following
MDT introduction, and this was accompanied by a
significant reduction in the proportion of patients
undergoing open and closed laparotomy and
thoracotomy. Operative mortality fell over fourfold
from 26% to 5.7%, while survival at 5 years for
patients undergoing potentially curative surgery
improved fivefold, from 10% to 52%. Moreover, the
referral rate by hospital clinicians to the MDT
increased significantly from one-third of patients in
the 1990s to over three-quarters in 2003.
There are a number of potential weaknesses of
this study. Retrospective case note review depends
Table 6 Outcome after esophagectomy related to individual
surgical teams
Surgeon 1 2 3 4 5 6 MDT (3+6)
Number of operations 2 2 7 10 16 17 53
Multimodal therapy 0 0 0 0 0 0 26
1 year survival (%) 40 100 29 40 56 46 81*
5 years survival (%) 0 50 0 0 12 6 49*
MDT, multidisciplinary team; *χ2 = 29.14, DF = 6, P = 0.0001.
© 2006 The Authors
Journal compilation © 2006 The International Society for Diseases of the Esophagus
Multidisciplinary team esophagectomy 169
on adequate documentation of appropriate data at
the time of presentation. Statistical comparisons
between various treatment groups may be invali-
dated by older patients with significant comorbidity
being treated by non-surgical means. Analysis of
subgroups within a study may lead to bias, while
comparisons of groups may prove to be not statisti-
cally significant simply because the study has insuf-
ficient power to demonstrate real differences.
Accurate preoperative staging of patients’ tumors
was not possible in the early 1990s. Identification of
patients who had received potentially curative
rather than palliative resection was difficult because
of inadequate information in the case notes. Hence
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the results after strictly curative resections may
have been better than the overall results reported
here. In any retrospective review, definition of the
case subjects and of the controls is critical in deter-
mining the outcome of the study and subsequent
conclusions. In this study we have chosen MDT
management, that is specific specialist consultant
investigation and treatment in the fields of gastro-
enterology, pathology, radiology, nursing, oncology,
anesthesia followed by consultant team surgery by
two specialist surgeons. Arguably, we could just as
easily have used time – before and after January
1998. However, in the mid-1990s the same two con-
sultant surgeons were practicing independently, but
without each other’s technical surgical support in
theatre, or the additional resource of the other key
upper gastrointestinal specialist team clinicians – in
particular, a specialist consultant oncologist and a
specialist consultant anesthetist. The overall surgi-
cal outcomes with these particular surgeons clearly
improved significantly (Table 6), following the intro-
duction of a multidisciplinary team framework.
Clearly this is not a randomized controlled trial
and the number of patients is relatively small, but
the results nonetheless demonstrate what can be
achieved by specialist care in a large district general
hospital in Britain. The improved outcomes cannot
be explained by poorer-than-average results in our
historical control group, as our results in the early
1990s are comparable with those reported by Sagar
et al. from a large UK teaching hospital.3 In this
latter study, potentially curative resection was pos-
sible in only 25% of patients, compared with 16%
at the Royal Gwent Hospital in the early 1990s.
Operative mortality was 27% after potentially cura-
tive esophagectomy (c.f. 26% in the present study)
and 5-year survival was 7% (c.f. 10%). The results
of surgical treatment of patients with esophageal
cancer at the Royal Gwent Hospital during the
early 1990s were therefore probably in keeping with
those of most other centers in the UK at that time.
Alterations in anesthetic and surgical technique
that occurred in the period of the study were
reflected in the operative procedures used. The
170 Diseases of the Esophagus
MDT group included patients who had transhiatal
esophagectomy10 and patients in whom somewhat
more extensive lymphadenectomies were performed
than had been the custom in the early 1990s. Critics
of the transhiatal Orringer esophagectomy have
suggested that it is an inadequate cancer operation,
which should be reserved for patients who have
impaired respiratory function. However, its propo-
nents argue that operative mortality and long-term
survival are at least as good as with standard resec-
tion techniques.11 Advocates of en-bloc resection
with extensive lymphadenectomy argue that improved
survival can only be achieved by meticulous wide
excision of the tumor and its lymphatic field12 as
has been reported in rectal cancer13 and stomach
cancer.14,15 We used transhiatal esophagectomy in
patients who were deemed to have T1/2 N0 carcino-
mas of the lower third of the esophagus irrespective
of cell type, and in patients classified as ASA III.
This approach is largely substantiated by the 5-year
survival of our patients, which was 37% after trans-
hiatal esophagectomy alone, compared with 38%
after transthoracic esophagectomy alone. Five-year
survival related to the surgical approach after neo-
adjuvant treatment was also similar at 75% after
transhiatal esophagectomy compared with 80%
after transthoracic esophagectomy.
Adjuvant or neoadjuvant chemotherapy and
radiotherapy have been associated with improve-
ments in local control and survival in several other
cancer sites, in particular breast and colorectal
cancer.16,17 However, similar therapeutic approaches
in the management of esophageal cancer have pro-
duced conflicting results. The large randomized UK
trial of neoadjuvant chemotherapy (OEO2)
reported a 2-year survival advantage of 43% versus
34% for patients who received two cycles of cispla-
tin and 5FU prior to surgical resection when com-
pared with surgery alone.18 This contrasts with the
US intergroup study, which failed to show any
overall benefit in survival after preoperative chemo-
therapy.19 Our results suggest a significant survival
benefit of 58% after neoadjuvant chemotherapy
with surgery, compared with 51% after surgery
alone. Neoadjuvant chemoradiotherapy is even
more controversial. Of the five randomized trials
reported, only Walsh et al. demonstrated a statisti-
cally significant survival advantage,20 while Urba
et al. demonstrated a 3-year survival advantage of
30% after chemoradiotherapy and surgery com-
pared with 16% after surgery alone.21 Our results
are in keeping with the above, with a 3-year sur-
vival of 68% for patients receiving neoadjuvant
chemoradiotherapy and surgery, compared with
37% after surgery alone. Absolute conclusions are
difficult to draw from the above trials, because of
the considerable heterogeneity that exists with
respect to radiation dose/fractionation, scheduling
Journal compilation © 2006 The International Society for Diseases of the Esophagus
of chemotherapy, histology and outcomes after sur-
gery alone. Moreover, many of the trials were
underpowered in statistical terms. It is possible that
overall improvements in survival from a combined
approach are offset by higher operative mortality
rates as suggested by Bosset et al.;22 indeed two-
thirds of our operative deaths occurred in patients
who had received preoperative chemoradiation.
Certainly good outcomes can be achieved with
definitive chemoradiation alone23 and the place of
selective surgery after definitive chemoradiation is
the subject of an ongoing European Organisation
for Research and Treatment of Cancer trial. A
potential further advantage of specialist multidisci-
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plinary teams is the identification of a significant
cohort of patients who, although not surgical can-
didates, may be suitable for treatment with poten-
tially curative chemoradiotherapy.
The true value of specialist surgical treatment
per se in improving outcomes for patients with
cancer of the esophagus remains uncertain. As far
as we are aware, there have been no studies of the
effectiveness of the service model recommended by
the National Health Service Executive, and any
relationship between patient throughput and sur-
vival remains controversial.5,24,25 Nonetheless, the
results of this study are encouraging, and mirror
our previous findings in the surgical treatment of
gastric cancer, where surgical subspecialization was
associated with significant improvements in out-
come.26,27 Furthermore, these findings support the
view that multiprofessional management can har-
ness the diverse talents of an array of specialist
clinicians with a common interest in upper gastro-
intestinal oncology, so that management plans are
stage-directed and patient-tailored, to optimize out-
comes after surgery for patients diagnosed with
cancer of the esophagus.
Acknowledgments
We grateful for the contribution of the following
Consultant General Surgeons who treated patients
with esophageal cancer in the early and mid-1990s
at the Royal Gwent Hospital: Mr D. E. Sturdy MS
FRCS, the late Mr G. Griffith OBE FRCS, the late
Mr M. Price Thomas FRCS, Mr K. D. Vellacott
DM FRCS.
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