Treating Esophageal Cancer by Stage

Most of the time, the initial treatment of esophagus cancer is based on its stage – how far it has spread. But other factors, such as a person’s overall health, can also affect treatment options. Talk to your doctor if you have any questions about the treatment plan he or she recommends.

Treating stage 0 esophagus cancer

A stage 0 tumor is not true cancer. It contains abnormal cells called high-grade dysplasia and is a type of pre-cancer. The abnormal cells look like cancer cells, but they are only found in the inner layer of cells lining the esophagus (the epithelium). They have not grown into deeper layers of the esophagus. This stage is often diagnosed when someone with Barrett’s esophagus has a routine biopsy.

Options for treatment typically include endoscopic treatments such as photodynamic therapy (PDT), radiofrequency ablation (RFA), or endoscopic mucosal resection (EMR). Long-term follow-up with frequent upper endoscopy is very important after endoscopic treatment to continue to look for pre-cancer (or cancer) cells in the esophagus.

Another option is to have the abnormal part of the esophagus removed with an esophagectomy. This is a major operation, but one advantage of this approach is that it doesn’t require lifelong follow-up with endoscopy.

Treating stage I esophagus cancer

In this stage the cancer has grown into some of the deeper layers of the esophagus wall (past the innermost layer of cells) but has not reached the lymph nodes or other organs.

T1 cancers: Some very early stage I cancers that are only in a small area of the mucosa and haven’t grown into the submucosa (T1a tumors) can be treated with EMR, usually followed by some type of endoscopic procedure to destroy any remaining abnormal areas in the esophagus lining.

But most patients with T1 cancers who are healthy enough will have surgery (esophagectomy) to remove the part of their esophagus that contains the cancer. Chemotherapy and radiation therapy (chemoradiation) may be recommended after surgery if there are signs that all of the cancer may not have been removed.

T2 cancers: For patients with cancers that have invaded the muscularis propia (T2 tumors), treatment with chemoradiation is often given before surgery. Surgery alone may be an option for smaller tumors (less than 2 cm). If the cancer is in the part of the esophagus near the stomach, chemo without radiation may be given before surgery.

If the cancer is in the upper part of the esophagus (in the neck), chemoradiation may be recommended as the main treatment instead of surgery. For some patients, this may cure the cancer. Close follow-up with endoscopy is very important in looking for possible signs of cancer returning.

People with stage I cancers who can’t have surgery because they have other serious health problems, or who don’t want surgery, may be treated with EMR and endoscopic ablation, chemo, radiation therapy, or both together (chemoradiation).

Treating stages II and III cancer of the esophagus

Stage II includes cancers that have grown into the main muscle layer of the esophagus or into the connective tissue on the outside of the esophagus. This stage also includes some cancers that have spread to 1 or 2 nearby lymph nodes.

Stage III includes some cancers that have grown through the wall of the esophagus to the outer layer, as well as cancers that have grown into nearby organs or tissues. It also includes most cancers that have spread to nearby lymph nodes.

For people who are healthy enough, treatment for these cancers is most often chemoradiation followed by surgery. Patients with adenocarcinoma at the place where the stomach and esophagus meet (the gastroesophageal junction) are sometimes treated with chemo (without radiation) followed by surgery. Surgery alone may be an option for some small tumors.

If surgery is the first treatment, chemoradiation may be recommended afterward, especially if the cancer is an adenocarcinoma or if there are signs that some cancer may have been left behind.

In some instances (especially for cancers in the upper part of the esophagus), chemoradiation may be recommended as the main treatment instead of surgery. Patients who do not have surgery need close follow-up with endoscopy to look for possible signs of remaining cancer. Unfortunately, even when cancer cannot be seen, it can still be present below the inner lining of the esophagus, so close follow-up is very important.

Patients who cannot have surgery because they have other serious health problems are usually treated with chemoradiation.

Treating stage IV cancer of the esophagus

Stage IV esophageal cancer has spread to distant lymph nodes or to other distant organs.

In general, these cancers are very hard to get rid of completely, so surgery to try to cure the cancer is usually not a good option. Treatment is used mainly to help keep the cancer under control for as long as possible and to relieve any symptoms it is causing.

Chemo may be given (possibly along with targeted drug therapy) to try to help patients feel better and live longer, but the benefit of giving chemo is not clear. Radiation therapy or other treatments may be used to help with pain or trouble swallowing. Another option at some point might be treatment with the immunotherapy drug pembrolizumab (Keytruda).

For cancers that started at the gastroesophageal (GE) junction, treatment with the targeted drug ramucirumab (Cyramza) may be an option at some point. It can be given by itself or combined with chemo. Another option at some point might be treatment with the immunotherapy drug pembrolizumab (Keytruda). 

Some people prefer not to have treatments that have serious side effects and choose to receive only treatments that will help keep them comfortable and add to their quality of life. For more information on treatments that may be helpful, see Palliative Therapy for Esophageal Cancer.

The American Cancer Society medical and editorial content team

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

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Last Medical Review: June 14, 2017 Last Revised: July 31, 2019

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