How Esophageal Cancer Is Treated

Treatment options for esophageal cancer depend on the stage of the cancer and may include surgery (removing part or all of the esophagus), chemotherapy, radiation therapy, targeted therapy, or clinical trials testing combinations of these or new treatments.

Treatment, however, goes beyond just treating the cancer, and palliative or supportive care—treatments aimed to help people cope with the physical, emotional, and spiritual side effects of cancer—are equally important.

Choosing a Treatment Center

Whether you will be having surgery or other treatments, finding a good cancer center is important. A 2017 study in the Annals of Surgery confirmed what earlier studies have shown. Researchers found that people with esophageal cancer who travel longer distances to high-volume cancer centers receive significantly different treatments and have better outcomes than those who stay closer to home at cancer centers that treat fewer people with the disease.

You may consider choosing to seek out an opinion at one of the larger National Cancer Institute-designated cancer centers; centers that treat large numbers of people with esophageal cancer (and for those who have surgery, perform more of these surgeries).

Treatment Options by Stage

Before going into the specific treatment options available, it's helpful to discuss the treatments most commonly used at different stages of the disease. They can vary tremendously.

Two people with the same stage of the disease, for example, may have cancers in different regions that would require different treatments. Even with cancers that are similar in location, stage, and in people with similar general health, it's important to note that no two cancers are alike.

That said, the general approach is as follows.

Stage 0

Stage 0 (carcinoma in situ) or extremely small stage 1A cancers may sometimes be removed via endoscopy. In the United States (unlike some parts of the world), esophageal cancer is uncommon and rarely found at a stage early enough that endoscopic removal is possible. Surgery can also be used for these tumors.

Stage 1

Surgery is usually the treatment of choice for stage 1 cancers and may be the only treatment needed in some cases.

Stage 2 and 3

Chemotherapy and radiation (or chemotherapy alone) followed by surgery is the most common approach, although sometimes surgery alone, or chemotherapy alone, may be used. There is currently controversy over whether people with squamous cell carcinomas of the esophagus who have a complete response (no evidence of tumor) after chemotherapy still require surgery.

Stage 4

With stage 4A cancers, chemotherapy and radiation therapy may sometimes be followed by surgery (if the tumor responds very well). For stage 4B cancers, chemotherapy can sometimes result in a partial response.

Some people worry that, because of age, treatment will be too aggressive, but older people (over the age of 80) who are in good general health appear to tolerate the treatments for esophageal well and have survival rates similar to those of younger people.

Surgery

When diagnosed in the earlier stages of the disease, surgery may offer the chance of a cure. Before considering surgery, careful staging is very important. Unfortunately, if a cancer has spread beyond the esophagus, surgery does not improve survival but does reduce quality of life. Therefore it is critical to determine who will benefit from surgery.

Equally important is finding a surgeon who is very experienced in performing these surgeries. While the large cancer centers are more likely to have surgeons with extensive experience, it's important to take the time to "interview" a potential surgeon about his or her personal experience with esophageal surgery.

Procedures

An esophagectomy, the surgery done to remove an esophageal cancer, refers to the removal of all or part of the esophagus. For some cancers, especially those in the lower esophagus, part of the stomach is removed as well. In addition, nearby lymph nodes are usually removed and sent to the pathology lab to look for any evidence of cancer.

After the section of the esophagus is removed, the stomach is reattached to the upper esophagus (the term that describes sewing these together is "anastomosis"). If a large part of the esophagus is removed so that reattachment is difficult or impossible, a section of intestine may be removed and placed between the upper esophagus and stomach.

An esophagectomy can be performed in two different ways:

  • Open esophagectomy: In an open procedure, a traditional large incision is made in either the neck, chest, or abdomen (or may sometimes include all three) through which the esophagus is accessed.
  • Minimally invasive esophagectomy: In a minimally invasive procedure, several small incision are placed in the neck and chest. A scope (with a camera) is inserted through these incisions and the surgery is performed through the scope. Minimally invasive surgery is usually only possible with smaller esophageal tumors.

Side Effects and Complications

Removing part of the esophagus is a major surgery and complications are not uncommon. During the surgery, the most common risks include bleeding and anesthesia concerns such as abnormal heart rhythms and lung problems.

In the days following surgery, blood clots are far too common (deep vein thromboses) and can sometimes break off and travel to the lungs (pulmonary emboli). Infections such as pneumonia are common during recovery and leakage (and subsequent infection and inflammation) may occasionally occur where the esophagus was reattached.

Long term, some people have persistent hoarseness due to damage to nerves in the chest during surgery. Nerve damage can also result in changes in motility in the upper digestive tract that may lead to nausea and vomiting. Since the lower esophageal sphincter (the band of muscle at the bottom of the esophagus that prevents the stomach contents from backing up into the esophagus) is often removed or damaged, heartburn is common, and many people will require medications for acid reflux.

Chemotherapy

Chemotherapy works by attacking rapidly dividing cells and can be given in one of several ways with esophageal cancer. These include:

  • Neoadjuvant chemotherapy: Neoadjuvant chemotherapy refers to the use of chemotherapy before surgery to reduce the size of a tumor.
  • Adjuvant chemotherapy: Adjuvant chemotherapy refers to chemotherapy given after surgery. Even if there does not appear to be any cancer left behind after surgery, small clusters of cancer cells can remain and result in a recurrence later on. Chemotherapy after surgery may reduce the risk of recurrence and improve survival for some people.
  • Palliative chemotherapy: Palliative chemotherapy refers to using chemotherapy to control symptoms and extend life with stage 4 disease, but not to cure the disease. At the current time, chemotherapy (even when combined with radiation) may increase the length of survival but is unlikely to cure the disease.

If surgery is being considered, the most common approach is to give chemotherapy (with or without radiation therapy) prior to surgery (adjuvant chemotherapy or chemoradiation). There are several reasons for this.

  • Your doctor can make sure the chemotherapy is effective rather than learning after the surgery if it is not.
  • Chemotherapy is usually tolerated much better before surgery than after surgery.
  • Neoadjuvant chemotherapy may downstage the tumor (make it smaller) so that surgery is easier to perform.
  • Finally, for some people (primarily those with squamous cell carcinomas), the tumor may disappear so that surgery is not needed.

Chemotherapy medications that are often used include a combination of Paraplatin (carboplatin) and Taxol (paclitaxel) or Platinol (cisplatin) and Camptosar (irinotecan). In the past, the medication 5-FU (5 fluorouracil) was often used, but tends to be more toxic.

Chemotherapy Side Effects

As with so many cancer treatments, it's important to keep in mind that the awful side effects of treatment a friend or family member may have experienced in the past, do not necessarily apply to the modern treatment of the disease. Chemotherapy drugs are usually given in cycles (for example, every three weeks), for four to six months.

Many of the side effects are due to the drugs killing off normal cells that divide rapidly along with cancer cells. Common side effects include:

Just as the chemotherapy drugs used today are less toxic, the management of side effects has improved dramatically. Many people have minimal or no nausea and vomiting with preventive medications. There are also injections available to increase the white blood cell count if needed (though it's still important to learn about ways to lower infection risk during chemotherapy).

Peripheral neuropathy (PN), is one of the more annoying symptoms of chemotherapy for esophageal cancer and is often permanent. The drugs linked most closely with PN include taxanes (such as Taxol), and platinum drugs (such as Platinol and Paraplatin). Since a combination of these are often used, the effect can be magnified.

There are many studies in progress looking at ways to reduce this symptom (such as using L-glutamine during treatment), and people should talk to their doctors about the latest research before starting chemotherapy.

Radiation Therapy

Radiation therapy uses high energy rays to treat cancer cells and is often used along with chemotherapy. Radiation therapy may also be used for palliation (see below). It is given in two primary ways:

  • External beam radiation: External beam radiation is the form many people are familiar with, and may be given daily for a few days or weeks.
  • Brachytherapy (internal) radiation therapy: With brachytherapy, an endoscopy is done so that the radiation can be placed near the tumor within the esophagus. It is done more often as palliative therapy to help with swallowing.

Radiation Side Effects

The most common side effects of radiation therapy to the chest are skin reddening and a rash at the site of radiation (similar to a sunburn) and fatigue. Radiation to the chest may also cause inflammation of the lungs (​radiation pneumonitis). If untreated it can lead to fibrosis of the lungs. Inflammation of the esophagus (pulmonary fibrosis) may also occur.

Targeted Therapy

Targeted therapy uses drugs just as chemotherapy, but the drugs are "targeted" against a particular pathway in the growth of cancer cells. For this ​reason they often have fewer side effects than traditional chemotherapy drugs.

Cyramza (ramucirumab)

Cyramza is a monoclonal antibody that is considered an angiogenesis inhibitor. In order for tumors to grow, they need to form new blood vessels (​angiogenesis). The drug prevents a step that is needed to form new vessels.

Cyramza is most often used when other treatments are no longer effective and may be used with or without chemotherapy. Side effects may include a headache and high blood pressure but on occasion severe symptoms, such as severe bleeding or intestinal perforation, may occur.

According to a 2017 study, out of all the chemotherapy and targeted therapy options available, Cyramza most clearly showed an ability to improve both progression-free survival and overall survival in people with advanced (stage 4) esophageal adenocarcinoma.

Herceptin (trastuzumab)

Herceptin is used on occasion for advanced esophageal adenocarcinomas that are HER2 positive (similar to HER2 positive breast cancer).

Testing for HER2 is done on a sample of a tumor obtained during a biopsy or surgery. These cancers have the protein HER2 on the surface of the cell, to which growth factors bind and cause growth. Herceptin binds to these receptors so that growth factors cannot, essentially starving the cancer.

Side effects are often mild, such as a headache and fever, and usually improve in time. The drug can, at times, cause heart damage. Your doctor will discuss the risk of this.

Clinical Trials

There are currently clinical trials in progress looking at combinations of the above treatments, as well as newer therapies such as immunotherapy drugs.

While participating in a research study can be frightening to some people, it helps to keep in mind that every treatment we currently have for esophageal cancer was once studied in a clinical trial.

Complementary Medicine (CAM)

At the current time, there are no "alternative" therapies that extend survival or result in a cure for people with esophageal cancer. That said, some treatments may help with the symptoms of cancer and cancer treatments when combined with conventional medicine.

Many of the larger cancer centers now offer these alternative cancer therapies along with conventional treatments for cancer. Therapies such as meditation, yoga, acupuncture, massage therapy, and more can sometimes help people cope with both the physical and emotional challenges that go along with a diagnosis of cancer.

Palliative Care

Palliative care differs from hospice care in that it may be used even for people who expect to be cured from their cancer. It is care that focuses on helping people manage the physical and emotional symptoms related to cancer and cancer treatments, ranging from cancer pain to depression.

Difficulty swallowing due to obstruction of the esophagus by tumor is common with esophageal cancer and interferes with proper nutrition. If a tumor is too advanced for surgery (esophagectomy) there are still options to reduce problems with swallowing. Some of these include:

  • Placing a stent in the esophagus (via endoscopy) to keep the esophagus open.
  • Brachytherapy (internal radiation) noted above.
  • External beam radiation therapy.
  • Electrocoagulation (burning the area of the tumor causing obstruction).
  • Laser therapy.

Many cancer centers now offer consults with a palliative care team. Working with a palliative care specialist often maximizes the chance that your symptoms will be well controlled and that your quality of life can be as good as possible while living with cancer.

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