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Cancer Medicine :: Esophageal Cancer Treatment

Esophagus Cancer

Treatment Options

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. 

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.

Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. 

For people with a tumor that has not spread beyond the esophagus and lymph nodes, doctors often recommend combining three types of treatment: radiation therapy, chemotherapy, and surgery. The order of treatments varies, and several factors are considered, including the type of esophageal cancer.

Particularly for squamous cell cancer, chemotherapy and radiation therapy (a combination called chemoradiotherapy) are commonly recommended as the first treatment, with surgery afterwards depending how well chemoradiotherapy worked. Recent studies show using either chemotherapy or chemoradiotherapy before surgery is better than surgery alone. 

For adenocarcinoma, the most common treatment in the United States is chemotherapy and radiation therapy followed by surgery. Surgery is almost always recommended after chemoradiotherapy, unless there are risk factors, such as a patient’s age or overall health.

For advanced esophageal cancer, treatment usually involves chemotherapy and radiation therapy. 

More detailed descriptions of these treatment options are listed below.

Palliative/supportive care

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it is addressed as quickly as possible. 

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. A surgical oncologist is a doctor who specializes in treating cancer using surgery. Surgery has traditionally been the most common treatment for esophageal cancer. However, currently, surgery is used as the primary (first) treatment only for patients with early-stage esophageal cancer.

For patients with locally-advanced esophageal cancer, a combination of chemotherapy and radiation therapy (see below), or chemotherapy alone in some situations, may be used before surgery to shrink the tumor. For people who cannot have surgery, the best treatment option is often a combination of chemotherapy and radiation therapy.

The most common surgery to treat esophageal cancer is called an esophagectomy, where the doctor removes the esophagus and then connects the remaining healthy part of the esophagus to the stomach so that the patient can swallow normally. The stomach or part of the intestine may sometimes be used to make the connection. The surgeon also removes lymph nodes around the esophagus.

Surgery for supportive care

In addition to surgery to treat the disease, surgery may be used to help patients eat and relieve symptoms caused by the cancer. This is called supportive or palliative surgery. To do this, surgeons and gastroenterologists (doctors who specialize in the gastrointestinal tract) can:  

Put in a percutaneous gastrostomy or jejunostomy (also called a feeding tube), so that a person can receive nutrition directly into the stomach or intestine. This may be done before chemotherapy and radiation therapy is given to make sure that the patient can eat enough food to maintain his or her weight and strength during treatment.

Dilate (expand) the esophagus. This procedure may have to be repeated if the tumor grows.

Put an esophageal stent into the esophagus. An esophageal stent is a metal, mesh device that is expanded to keep the esophagus open.

Use photodynamic therapy (lasers or light therapy; see below) to destroy cancerous tissue and relieve blockages

Create a bypass, or new pathway, to the stomach (if a tumor blocks the esophagus but cannot be removed with surgery); this procedure is rarely used.

People who have had trouble eating and drinking may need intravenous (IV; into a vein) feedings and fluids for several days before and after surgery, as well as antibiotics to prevent or treat infections. Patients learn special coughing and breathing exercises to keep their lungs clear.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation treatment is given directly inside the body, it is called internal radiation therapy or brachytherapy. For esophageal cancer, this involves temporarily inserting a radioactive wire into the esophagus using an endoscope.

Side effects from radiation therapy may include fatigue, mild skin reactions, soreness in the throat and esophagus, difficulty or pain with swallowing, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

As explained above, chemotherapy and radiation therapy are often given at the same time to treat esophageal cancer. Recent studies also show that chemotherapy alone (without radiation therapy) may work as well, but more research is needed to understand any benefits of chemotherapy alone compared with chemoradiotherapy.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, hair loss, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. 

Photodynamic therapy

Photodynamic therapy is a palliative or supportive option used to make swallowing easier, especially for people who cannot or choose not to have surgery, radiation therapy, or chemotherapy. In photodynamic therapy, a light-sensitive substance is injected into the tumor and stays longer in cancer cells than in healthy cells. A laser is then aimed at the tumor, destroying the cancer cells. Although photodynamic therapy may relieve swallowing problems for a short period of time, it does not cure esophageal cancer.

Electrocoagulation 

This type of palliative treatment helps kill cancer cells by heating them with an electric current. This is sometimes used to help relieve symptoms by removing a blockage caused by the tumor.

Recurrent esophageal cancer

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED.

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. 

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, chemotherapy, and radiation therapy) but may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. 

Metastatic esophageal cancer

If cancer has spread to another location in the body, it is called metastatic cancer. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. 

For metastatic esophageal cancer, supportive care is very important to help relieve symptoms and side effects. The goal of treatment is usually to lengthen a person’s life, while easing symptoms such as pain and problems with eating. Your health care team may recommend a treatment plan that includes chemotherapy, as well as radiation therapy to help relieve pain or discomfort. An esophageal stent, laser therapy, or photodynamic therapy may help keep the esophagus open (see above).

For many patients, a diagnosis of metastatic cancer can be very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

If treatment fails

Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Palliative care given toward the end of a person’s life is called hospice care. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families.

Coping with Side Effects

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for esophageal cancer are described in detail within the Treatment section.  Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with esophageal cancer. 

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. 

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care.

After Treatment

After treatment for esophageal cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. 

If the cancer is in remission, follow-up care may include CT scans and an upper endoscopies  to watch for a possible recurrence.

People who have had an esophagectomy should sleep with the head of the bed elevated to avoid acid reflux, as the stomach has been surgically moved up into the chest.

People recovering from esophageal cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. For esophageal cancer survivors who smoke, quitting smoking can help recovery and reduce the risk of cancer recurrence. 

Moderate exercise can help you rebuild your strength and energy level. Talk with your doctor about helping you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level.

Latest Research

Doctors are working to learn more about esophageal cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Chemoprevention. Researchers are looking at using aspirin and antacids to prevent esophageal adenocarcinoma in people with Barrett’s esophagus. Research is still ongoing, and people are encouraged to talk with their doctor before taking any medications or dietary supplements.

PET scan. In addition to help stage of esophageal cancer , PET scans may also be used to find out how well chemotherapy is working to shrink a tumor before surgery. Researchers are studying the use of PET scan to evaluate and possibly change chemotherapy before surgery.

Chemotherapy advances. Doctors are studying combinations of different drugs, such as cisplatin (Platinol), fluorouracil (5-FU, Adrucil), paclitaxel (Taxol), irinotecan (Camptosar), docetaxel (Docefrez, Taxotere), oxaliplatin (Eloxatin), and capecitabine (Xeloda). And, research is ongoing to find new drugs that are effective for esophageal cancer.

Targeted therapy. Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to normal cells.

About 20% to 30% of esophageal adenocarcinomas make too much of a protein called human epidermal growth receptor 2 (HER2). Adding the drug trastuzumab (Herceptin), which targets HER2, to chemotherapy for metastatic esophageal adenocarcinomas improves the effectiveness of chemotherapy for patients with a cancer that makes too much HER2. Researchers are looking at newer drugs that target HER2 for advanced esophageal adenocarcinomas, as well as combining trastuzumab with radiation therapy.

Another type of growth factor, called c-MET, may play an important role in helping metastatic esophageal adenocarcinomas grow. Researchers are studying drugs that stop c-MET from helping a cancer grow combined with chemotherapy for patients with metastatic esophageal adenocarcinomas.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current esophageal cancer treatments in order to improve patients’ comfort and quality of life.

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