Chemotherapy for Esophageal Cancer

Chemotherapy (chemo) is anti-cancer drugs that may be given intravenously (injected into your vein) or by mouth. The drugs travel through the bloodstream to reach cancer cells in most parts of the body.

By itself, chemo rarely cures esophageal cancer so it is often given with radiation therapy (called chemoradiation).

When is chemotherapy used for esophageal cancer?

Chemo may be used at different times during treatment for esophageal cancer.

• After surgery (adjuvant chemotherapy): Adjuvant chemo might be given (often with radiation) to kill any cancer cells that might have been left behind or have spread but are too small to see on imaging tests. If these cells were allowed to grow, they could form new tumors in other places in the body. It isn’t clear that adjuvant chemoradiation is as helpful as giving it before surgery.
• Before surgery (neoadjuvant chemotherapy): For some cancers, neoadjuvant chemo might be given (often with radiation) to try to shrink the cancer so it can be removed with less extensive surgery. This can lower the chance of the cancer coming back and help people live longer than using surgery alone.
• Chemo for advanced cancers: For cancers that have spread to other organs, such as the liver, chemo can also be used to help shrink tumors and relieve symptoms. Although it is not likely to cure the cancer, it often helps people live longer.

Drugs used to treat esophageal cancer

Some common drugs and drug combinations used to treat esophageal cancer include those below which can be given along with radiation or without:

• Carboplatin and paclitaxel (Taxol)
• Oxaliplatin and either 5-FU or capecitabine
• Cisplatin and either 5-fluorouracil (5-FU) or capecitabine
• Cisplatin and Irinotecan (Camptosar)
• Paclitaxel (Taxol) and either 5-FU or capecitabine

Other common drugs and drug combinations that can be used to treat esophageal cancer but are usually not given with radiation include:

• ECF: epirubicin (Ellence), cisplatin, and 5-FU (especially for gastroesophageal junction tumors)
• DCF: docetaxel (Taxotere), cisplatin, and 5-FU
• Trifluridine and tipiracil (Lonsurf), a combination drug in pill form

For some esophagus cancers, chemo may be used along with a targeted drug such as trastuzumab (Herceptin) or ramucirumab (Cyramza), or with an immunotherapy drug.

How is chemotherapy given?

Chemo drugs for esophageal cancer are typically given into a vein (IV), either as an injection over a few minutes or as an infusion over a longer period of time. Some drugs you take by mouth. All of these drugs enter your bloodstream and reach most areas of your body. These drugs can be given in a doctor’s office, infusion center, or in a hospital.

Often, a slightly larger and sturdier IV called a central venus catheter (CVC) is needed to administer chemo. It might also be called a central venous access device (CVAD), or central line. Once put in place, a CVC can stay in as long as you’re getting treatment so you won’t need to be stuck with a needle in the arms or hands each time to put in an IV catheter. It can be used to put medicines, blood products, nutrients, or fluids right into your blood. It can also be used to take out blood for testing. There are many different kinds of CVCs. The most common types are the port and the PICC line.

Chemo is given in cycles, followed by a rest period to give you time to recover from the effects of the drugs. Cycles are most often 2 or 3 weeks long. The schedule varies depending on the drugs used. For example, with some drugs, the chemo is given only on the first day of the cycle. With others, it is given for a few days in a row, or once a week. Then, at the end of the cycle, the chemo schedule repeats to start the next cycle.

Adjuvant or neoadjuvant chemo is often given for a total of 3 to 6 months, depending on the drugs used. The length of treatment for advanced esophageal cancer depends on how well it is working and what side effects you might have.

Possible side effects of chemotherapy

Chemo drugs can cause side effects. These depend on the type and dose of drugs given, and the length of treatment. Some of the most common side effects of chemo include:

• Nausea and vomiting
• Loss of appetite
• Hair loss
• Mouth sores
• Diarrhea or constipation

Chemo can also affect the blood-forming cells of the bone marrow, which can lead to:

• Increased chance of infection (from having too few white blood cells)
• Easy bleeding or bruising (from having too few blood platelets)
• Fatigue (from having too few red blood cells and other reasons)

Other side effects are also possible. Some of these are more common with certain chemo drugs. For example:

• Hand-foot syndrome. During treatment with capecitabine or 5-FU (when given as an infusion), this can start out as redness in the hands and feet, and then progress to pain and sensitivity in the palms and soles. If it worsens, blistering or skin peeling can occur, sometimes leading to painful sores. It’s important to tell your doctor right away about any early symptoms, such as redness or sensitivity, so that steps can be taken to keep things from getting worse.
• Neuropathy (nerve damage). This is a common side effect of oxaliplatin, cisplatin, docetaxel, and paclitaxel. Symptoms include numbness, tingling, and even pain in the hands and feet. Oxaliplatin can also cause intense sensitivity to cold in the throat and esophagus (the tube connecting the throat to the stomach) and the palms of the hands. This can cause problems swallowing liquids or holding a cold glass. If you will be getting oxaliplatin, talk with your doctor about side effects, and let them know right away if you develop numbness and tingling or other side effects.
• Allergic or sensitivity reactions. Some people can have reactions while getting the drug oxaliplatin. Symptoms can include skin rash, chest tightness and trouble breathing, back pain, or feeling dizzy, lightheaded, or weak. Be sure to tell your nurse right away if you notice any of these symptoms while you are getting chemo.
• Diarrhea. This is a common side effect with many of these drugs, but can be particularly bad with irinotecan. It needs to be treated right away — at the first loose stool — to prevent severe dehydration. This often means taking drugs like loperamide (Imodium). If you are on a chemo drug that is likely to cause diarrhea, your doctor will give you instructions on what drugs to take and how often to take them to control this symptom.
• Weight loss. People with esophageal cancer often have already lost weight before the cancer was found. Treatments such as chemo, radiation, or both can make it hard to eat well enough to get good nutrition, making weight loss worse. Depending on your situation, the cancer care team might recommend placement of a feeding tube to keep up your nutrition and weight during treatment. This feeding tube may be used short-term (during treatment and a bit afterwards) or it may be permanent depending on your cancer. To learn more, see Supportive Care for Esophageal Cancer.

Most of these side effects tend to go away after treatment is finished. Some, such as hand and foot numbness, may last for a long time. There are often ways to lessen these side effects. For example, you can be given drugs to help prevent or reduce nausea and vomiting.

Be sure to discuss any questions about side effects with your cancer care team. Report any side effects or changes you notice while getting chemo right away so that they can be treated promptly. In some cases, the doses of the chemo drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.