ORIGINAL ARTICLE Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer: a prognostic model to guide treatment selection Ewout W. Steyerberg, PhD, Marjolein Y. V. Homs, PhD, Annemieke Stokvis, BSc, Marie-Louise Essink-Bot, MD, PhD, Peter D. Siersema, MD, PhD, for the SIREC Study Group Rotterdam, The Netherlands Background: Brachytherapy was found to be preferable to metal stent placement for the palliation of dysphagia because of inoperable esophageal cancer in the randomized SIREC trial. The benefit of brachytherapy, however, only occurred after a relatively long survival. The objective is to develop a model that distinguishes patients with a poor prognosis from those with a relatively good prognosis. Methods: Survival was analyzed with Cox regression analysis. Dysphagia-adjusted survival (alive with no or mild dysphagia) was studied with Kaplan-Meier analysis. Patient data is from the multicenter, randomized, controlled trial (SIREC, n Z 209) and a consecutive series (n Z 396). Patients received a stent or single-dose brachytherapy. Results: Significant prognostic factors for survival included tumor length, World Health Organization performance score, and the presence of metastases (multivariable p ! 0.001). A simple score, which also included age and gender, could satisfactorily separate patients with a poor, intermediate, and relatively good prognosis within the SIREC trial. For the poor prognosis group, the difference in dysphagia-adjusted survival was 23 days in favor of stent placement compared with brachytherapy (77 vs. 54 days, p Z 0.16). For the other prognostic groups, brachytherapy resulted in a better dysphagia-adjusted survival. Conclusions: A simple prognostic score may help to identify patients with a poor prognosis in whom stent placement is at least equivalent to brachytherapy. If further validated, this score can provide an evidence-based tool for the selection of palliative treatment in esophageal cancer patients. (Gastrointest Endosc 2005;62:333-40.) Annually, approximately 400,000 patients are diagnosed with esophageal cancer worldwide. More than 50% of these patients require palliative treatment to relieve progressive dysphagia. 1 Stent placement and single-dose brachyther- apy (also called intraluminal radiotherapy) are both widely used treatment modalities for dysphagia because of inoperable esophageal cancer. 2-6 We recently reported the results of a large randomized trial that compared these treatment modalities (Stent versus Intraluminal Radiother- apy for Inoperable Esophageal Carcinoma [SIREC] study). 7 We demonstrated that brachytherapy gave a better long- term relief of dysphagia than stent placement. It, therefore, was preferable as the initial treatment of dysphagia because of inoperable esophageal cancer. Costs of both treatments were similar. 8 Our findings suggest that brachytherapy may need to be considered more often in the palliative care of esophageal cancer patients. However, because dysphagia improved more rapidly after stent placement than after brachytherapy, stent placement as the initial treatment might be reserved for patients with a short-life expectancy who need a more instant relief of dysphagia. 7 Presently, no prognostic model has been developed that can be used to identify the group of patients with a poor prognosis. Several prognostic factors have been described in the literature, most of which are related to the extent of disease and the patient’s physical condi- tion. 5,9-12 We aimed to develop and to validate a prognostic model for patients who require palliation for dysphagia from esophageal cancer. This model should be able to guide the choice for palliative treatment, with stent placement for those who need relief of dysphagia at short term and brachytherapy for those who have a longer life expectancy. For greater generalizability of the model, we analyzed patients randomized in the SIREC trial 7 and a consecutive series of patients from our hospital. 13-17 See CME section; p. 413. Copyright ª 2005 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(05)01587-7 www.mosby.com/gie Volume 62, No. 3 : 2005 GASTROINTESTINAL ENDOSCOPY 333