In 2013, for patients with a locally advanced oesophageal cancer, there is a survival benefit in patients who have either neoadjuvant chemoradiotherapy (CRT) or chemotherapy (CT). The latest meta-analysis suggests a benefit of CRT over CT by a factor of 3% at two years with more of an effect on adenocarcinoma for both treatments and CRT for SCC¹. There are four positive randomised control trials supporting CRT and CT prior to surgery. The trials before 2000 were commonly under powered, had mixed histology, had unreliable staging and had limited or no quality surgery control. Trails published after 2000 from France and Japan have supported the use of pre CT based on cisplatin (C) and 5 fluro-uracil (5FU). In the USA, the Netherlands and China pre CRT with either CF or a combination of a either cisplatin or carboplatin with placitaxol have been positive in cohorts with mixed histology or SCC.

There are no appropriately powered trials comparing pre CT with pre CRT. Presently there are randomised trials in Scandinavia, Japan and Ireland assessing the role of RT with CT. We await the outcome of the UK, MRC trial (OEO 5) of two cycles of pre CT (CF) compared with four cycles of epirubicin combined with CF. For an individual with an oesophageal cancer, all patients should be offered preoperative therapy based on cisplatin and more recently there is evidence to support the combination with a taxane. There is clearly a role for radiotherapy in patients, but it is not clear whether this should be every patient. The standard treatment in individual centres will have been chosen by the centre treating the patient according to their assessment of the literature and local experiences and biases.

The optimal treatment would be to individualise the therapy according to the stage of the disease (T and N) along with using data from the tumour with respect to the potential for the patient to have a response to the proposed therapy. Most importantly, the role of appropriate local clearance of the cancer performed by experienced surgeons in high volume centres is a vital component in the care and potential optimal outcome in these patients.