Session co-moderator, Pretesh R. Patel, MD, Associate Professor of Radiation Oncology at Winship Cancer Institute of Emory University, shared his thoughts on the Neo-AEGIS1 findings with The ASCO Post. “I think we continue to have equipoise about chemoradiation and perioperative chemotherapy in this patient population,” he concluded from the study results.
Although a few other studies have evaluated neoadjuvant chemoradiation and perioperative chemotherapy, Neo-AEGIS is the first to compare the two approaches in a randomized, head-to-head fashion, Dr. Patel noted. “Encouragingly, we are seeing [primary] outcomes to be the same in the two arms,” he said. “We are looking forward to subgroup analyses to help us decide which treatment paradigm might be better for a particular type of patient.”
Pretesh R. Patel, MD
According to Dr. Patel, the toxicity with the multimodal regimen of chemoradiation was “clearly more favorable” than that associated with perioperative chemotherapy and was “usually managed very easily.” He predicted this will be borne out by forthcoming quality-of-life data. Dr. Patel also noted that the toxicity seen with the Neo-AEGIS regimen in this study might be an underestimate of what is being seen in today’s real-world setting where the combination of fluorouracil, leucovorin, oxaliplatin, and docetaxel is generally used; in the study, only 15% of patients were treated with this regimen.
As to why all the pathologic proxy markers favored chemoradiation yet there was no difference in the survival curves, Dr. Patel and others have hypothesized that “distant metastasis may be suboptimally controlled in the chemoradiation arm. This could be the driver that washes out the benefit of better pathologic response…. We await the patterns-of-failure analysis to confirm this.”
Of note, both approaches lacked the addition of adjuvant nivolumab, which is now a standard treatment component after chemoradiation and surgery for this cancer, at least in the United States. “Adjuvant nivolumab after chemoradiation and surgery in patients with residual disease is the current standard of care, as it improved distant metastasis–free survival by 26% in CheckMate 577,2” Dr. Patel commented.
DISCLOSURE: Dr. Patel reported no conflicts of interest.
REFERENCES
1. Reynolds JV, Preston SR, O’Neill B, et al: Neo-AEGIS (neoadjuvant trial in adenocarcinoma of the esophagus and esophago-gastric junction international study): Final primary outcome analysis. 2023 ASCO GI Cancers Symposium. Abstract 295. Presented January 19, 2023.
2. Kelly RJ, Ajani JA, Kuzdzal J, et al: Adjuvant nivolumab in resected esophageal or gastroesophageal junction cancer. N Engl J Med 384:1191-1203, 2021.
