How Esophageal Cancer Is Treated

As with most types of cancer, the treatment for esophageal cancer depends in large part on how advanced it is. When caught in an early stage, before it has a chance to spread beyond the esophagus, removing it with surgery is often effective.

When surgery alone is not effective, medication—chemotherapy, targeted therapy, immunotherapy, or a combination—may be necessary. Radiation also is sometimes added to esophageal cancer treatment. And because this type of cancer is especially aggressive and challenging to treat, some patients may be encouraged to participate in clinical trials when it's clear more conventional approaches are not likely to work.

For patients with esophageal cancer who can't be cured, palliative measures to relieve symptoms and help them, and their loved ones, cope is the primary goal of treatment.

Surgery and Specialist-Driven Procedures

Surgery almost always is the primary treatment for esophageal cancer. The procedure used will depend on how advanced the disease is.

Endoscopy

This procedure may be used to remove small, stage 0 esophageal tumors, also known as carcinoma in situ, or extremely small stage 1A cancers. It involves inserting an endoscope through the mouth or an incision in the skin. The surgeon will use an instrument attached to the scope to cut away the diseased part of the esophagus and remove it.

Esophagectomy

Surgery for esophageal cancer is called esophagectomy. It involves removing all or part of the esophagus. Often lymph nodes near the tumor are removed as well and sent to a pathology lab to see if the cancer has spread. When the cancer is in the lower part of the esophagus, near the stomach, the portion of the stomach affected also may be removed.

After a section of the esophagus is removed, the remaining portion is reattached to the stomach in a procedure called anastomosis. If so much esophagus is removed that it will be too difficult, or impossible, to reconnect it, the surgeon may remove a section of the intestine and use it to link the upper esophagus and stomach.

There are two types of esophagectomy:

• Open esophagectomy, in which a surgeon makes a large incision in the neck, chest, or abdomen—or sometimes all three—in order to get to the esophagus
• Minimally invasive esophagectomy, in which the surgeon makes several small incisions in the neck and chest through which they insert a scope and surgical instruments. This procedure typically can only be used for small tumors.

Both types of esophagectomy come with risks and complications, among them:

• Bleeding
• Side effects from anesthesia such as abnormal heart rhythm and lung problems
• Blood clots that can break off and travel to the lungs (pulmonary emboli)
• Infections such as pneumonia
• Leakage, infection, and inflammation where the esophagus was reattached to the stomach
• Long-term hoarseness
• Nausea and vomiting caused by changes in motility (movement) in the upper digestive tract
• Heartburn and acid reflux due to removal of or damage to the lower esophageal sphincter, the band of muscle at the bottom of the esophagus that prevents what's in the stomach from coming back up into the throat

Chemotherapy

Chemotherapy involves using medication to kill cancer cells. It's used in a number of ways to treat esophageal cancer:

• Neoadjuvant chemotherapy: Chemotherapy is given before surgery to downstage the tumor, and make it smaller and easier to remove. Often this is the best approach because the side effects are easier to tolerate before surgery.
• Adjuvant chemotherapy: Chemotherapy is given after surgery to destroy any remaining cancer cells. The goal is to reduce the risk of recurrence and improve survival.
• Palliative chemotherapy: This is done to control symptoms in someone with stage 4 (very advanced) cancer. It may extend life but is not likely to cure the disease.

The chemotherapy drugs used most often for esophageal cancer include:

• Paraplatin (carboplatin) plus Taxol (paclitaxel)
• Platinol (cisplatin) plus Camptosar (irinotecan)
• Oxaliplatin
• Docetaxel
• 5-FU (fluorouracil)

Chemotherapy drugs usually are given in cycles—for example, every three weeks—for four to six months. During that time, they may or may not cause any number of side effects. These occur largely because the medication destroys healthy cells along with cancerous ones.

Among the most common side effects of chemotherapy are:

• Changes in blood counts: Low blood counts (bone marrow suppression) resulting in a low white blood cell count (neutropenia), a low red blood cell count (anemia), and a low platelet count (thrombocytopenia)
• Hair loss
• Nausea and vomiting
• Peripheral neuropathy: Tingling, numbness, and/or pain in the hands and feet that may be permanent
• Mouth sores
• Changes in how things taste
• Fatigue

Often side effects can be prevented or managed with medication. These include injections to increase white blood cells and help prevent infection.

Radiation Therapy

Radiation therapy involves using high-energy radiation to kill cancer cells. It often is combined with chemotherapy, a practice called chemoradiotherapy. Radiation also may be used to help relieve symptoms.

Two types of radiation therapy are used to treat esophageal cancer:

• External beam radiation directs radiation from outside of the body toward the area where cancer cells are located. It may be given daily for a few days or weeks and can cause side effects such as a rash or reddening of the skin the beam passes through that's similar to a sunburn.
• Brachytherapy (internal) radiation therapy bypasses the skin by placing needles, wires, seeds, or catheters containing a radiative substance inside the body near the tumor. It's used most often as palliative therapy to help with swallowing.

Side effects of both types of radiation include fatigue, inflammation of the esophagus (esophagitis), and radiation pneumonitis—lung inflammation that can lead to fibrosis.

Immunotherapy

Although immunotherapy is a relatively new treatment for esophageal cancer, it can be highly effective. This approach is based on the fact the immune system can recognize and destroy cancer cells, just as it does viruses and bacteria. It involves using medication to help the immune system do this job by targeting certain proteins on immune system cells called checkpoint proteins.

Cancer cells often use checkpoint proteins to prevent being attacked by the immune system. Immunotherapy medications work by targeting checkpoint proteins and are known as immune checkpoint inhibitors.

Three checkpoint inhibitors are used to treat esophageal cancer. Each is approved to treat people who have advanced esophageal cancer or gastroesophageal cancer (meaning the stomach as well as the esophagus is affected):

• Jemperli (dostarlimab)
• Opdivo (nivolumab)
• Keytruda (pembrolizumab)
  

Targeted Therapy

Like chemotherapy, targeted therapy uses medication to destroy cancer cells. The difference is that the drugs affect only those cells, leaving healthy ones intact. For this ​reason, they often have fewer side effects than traditional chemotherapy drugs.

There are three targeted therapy medications for esophageal cancer:

Cyramza (ramucirumab) is a monoclonal antibody known as an angiogenesis inhibitor. It works by preventing tumors from forming new blood vessels in a process called ​angiogenesis. It may be used with or without chemotherapy, most often when other treatments stop working.

Side effects include headache, swelling of the arms or legs, protein in the urine, and fatigue. In rare cases, ramucirumab has been shown to cause blood clots, perforations (holes) in the intestines or stomach that could lead to infection, and problems with the healing of wounds. It's given intravenously (by IV) every two weeks.

Herceptin (trastuzumab) also is a monoclonal antibody. It sometimes is used for advanced esophageal HER2-positive adenocarcinomas, in which proteins called HER2 are on the surface of the cancer cells.

Hercepetin binds to growth factors on these cells which stops them from multiplying. The typical side effects of Herceptin, headache and fever, tend to be mild and improve over time. However, the drug has been known to cause heart damage.

Herceptin is given by injection once every three weeks along with chemotherapy.

Enhurtu (fam-trastuzumab deruxtecan) combines a monoclonal antibody with a chemotherapy drug. The antibody attaches to the HER2 protein on the cancer cell and signals the chemotherapy medication where to go. It is given once every three weeks by infusion.

Complementary and Alternative Medicine

Alternative therapies such as meditation, yoga, and acupuncture will not help to cure esophageal cancer. However, such treatments can help relieve symptoms and make it easier to cope with the stresses of having a serious disease and dealing with treatment side effects.

Many of the larger cancer centers now offer alternative cancer therapies along with conventional treatments for cancer.

Palliative Care

Palliative care focuses on helping people manage the physical symptoms and emotional aspects of cancer and treatment side effects ranging from pain to depression.

In the case of esophageal cancer, a tumor can make it hard to swallow and prevent a patient from getting proper nutrition. Palliative care often focuses on managing this. Among the measures taken:

• Placing a stent (tiny tube) in the esophagus to keep it open
• Brachytherapy (internal radiation)
• External beam radiation therapy
• Electrocoagulation (burning the area of the tumor that's causing blockage)
• Laser therapy

Summary

The first line treatment for esophageal cancer almost always is surgery unless the disease is so advanced it would be impossible to remove it all. There are several other treatments that can be used along with surgery to destroy remaining cancer cells and help prevent new ones from developing. These include chemotherapy, targeted therapy, immunotherapy, and radiation.

A Word From Verywell

Esophageal cancer is one of the most challenging cancers to manage. It's important to find a healthcare team that has experience and expertise in treating it. A large cancer center designated by the National Cancer Institute is a good place to start, even if it isn't close by. A 2017 study in the Annals of Surgery found people with esophageal cancer who travel to high-volume cancer centers receive significantly different treatments and have better outcomes than those who stay closer to home. You might also consider talking to your healthcare provider about participating in a clinical trial if existing treatments aren't working.

Esophageal Cancer Healthcare Provider Discussion Guide

Get our printable guide for your next healthcare provider's appointment to help you ask the right questions.

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