Is it time to retire preoperative radiation for localized esophageal and gastro-esophageal adenocarcinoma?

Whether preoperative chemoradiotherapy (CRT) or perioperative chemotherapy is superior for localized esophageal or gastro-esophageal junction (GEJ) cancers has been a topic of long-standing debate. For years, standard of care in the United States for localized esophageal or GEJ adenocarcinoma (EAC) has been physician's choice between the 2 strategies. More recently, adjuvant immunotherapy has also been introduced into the treatment approach for those who received neoadjuvant CRT. While preoperative radiation remains an important option for patients with esophageal squamous cell carcinomas, the ESOPEC trial presented in 2024 suggested that perioperative chemotherapy is superior to preoperative CRT in EAC. In addition, the results of the TOPGEAR trial presented in 2024 showed that adding CRT to perioperative chemotherapy did not lead to improved outcomes. This has led to a shift in practice among oncologists. However, there are various complexities and factors to consider when interpreting these studies. In this review, we outline both trials and what their findings may mean for the future of preoperative CRT in EAC. Ultimately, until more data are available that incorporate novel agents such as immunotherapy, these studies indicate that we should defer the routine inclusion of radiation in preoperative treatment for EAC.