Treating Esophageal Cancer

A stage 0 tumor contains abnormal cells called high-grade dysplasia and is a type of precancer. This stage is often diagnosed when someone with Barrett’s esophagus has a biopsy.

Options for treatment typically include endoscopic treatments such as:

• Endoscopic mucosal resection (EMR)
• Endoscopic submucosal dissection (ESD)
• Radiofrequency ablation (RFA)
• Photodynamic therapy (PDT)
• Cryotherapy

Sometimes, more than one type of treatment might be used. For example, EMR or ESD might be followed by RFA.

Long-term follow-up with regular upper endoscopy is very important after endoscopic treatment to continue to look for precancer (or cancer) cells in the esophagus.

Another option is to have the abnormal part of the esophagus removed with an esophagectomy. This was used more often in the past, but this is a major operation with serious potential side effects, so it’s not often used for stage 0 cancers today.

In general, most stage I and II esophageal cancers are potentially resectable (removable by surgery). Most stage III cancers are potentially resectable as well, even if they’ve spread to nearby lymph nodes, as long as the cancer hasn’t grown into vital structures such as the trachea (windpipe), the aorta (the large blood vessel coming from the heart), or the spine.

In general, treatment is aimed at trying to cure these cancers.

Depending on the type and stage of the cancer, where it is in the esophagus, and a person’s overall health, treatment options might include:

• Endoscopic treatments for some stage I cancers, or for people who aren’t healthy enough for other treatments. These may include treatments such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), or ablative therapies like radiofrequency ablation (RFA), photodynamic therapy (PDT), or cryotherapy. Sometimes EMR or ESD might be followed by an ablative therapy.
• Surgery (esophagectomy), either alone or with chemotherapy and/or chemoradiation (chemo plus radiation therapy). Chemotherapy is commonly given before and after surgery, while chemoradiation is typically only given before surgery.
• Chemoradiation alone, especially for people who can’t have surgery for other health reasons.
• Radiation alone, for people in whom chemotherapy may be too risky.
• Immunotherapy might also be part of treatment for some people at some point.

Some people have esophageal cancer that hasn’t spread to other parts of the body but that still can’t be removed completely. Examples include cancers that have grown into nearby vital structures such as the trachea (windpipe), the aorta (the large blood vessel coming from the heart), or the spine.

Other people might have cancer that is potentially resectable, but they might not be healthy enough for surgery or might not want surgery.

Esophageal cancers that can’t be removed can be very hard to cure, and often the focus is on maintaining a person’s quality of life and preventing or improving symptoms such as trouble swallowing, pain, and bleeding into the esophagus.

Depending on the type and stage of the cancer, where it is in the esophagus, and a person’s overall health, treatment options might include:

• Chemoradiation
• Radiation therapy, for patients in whom chemotherapy may be too risky.
• Chemotherapy alone, in people who can’t get radiation for some reason. Chemotherapy is sometimes administered together with immunotherapy.
• Endoscopic treatments, in some people with earlier stage cancers who aren’t healthy enough for surgery. These may include endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), or ablative therapies like radiofrequency ablation (RFA), photodynamic therapy (PDT), or cryotherapy.

While it’s not common, sometimes treatment might shrink a cancer enough so that surgery becomes possible later on. If this happens, it’s important to discuss the risks and benefits of surgery with your doctors so you can make an informed decision that’s right for you.

In general, esophageal cancers that have spread to other parts of the body are very hard to get rid of completely, so surgery to try to cure the cancer is usually not an option. Treatment is usually aimed at keeping the cancer under control for as long as possible and preventing or relieving symptoms to help maintain a person’s quality of life.

Medicines, including chemotherapy, immunotherapy, and targeted drugs, are the most common treatments for these cancers, either alone or in combination. If you have advanced cancer, your doctor will likely order tests of your cancer cells for certain biomarkers, which can help tell which of these treatments might be best for you.

In general, treatment options might include:

• Chemotherapy, either alone or with an immunotherapy or targeted drug therapy
• Immunotherapy alone
• Targeted drug therapy alone

If one of these treatments isn’t helpful or if it stops working, another can often be tried, as long as a person is healthy enough.

Treatment aimed at preventing or relieving symptoms is also an important part of treatment. For example, if the cancer is making it hard to swallow or eat, treatments that might be helpful include:

• Endoscopic treatments
• Radiation therapy

A recurrence means the cancer has come back after treatment has been completed. The recurrence may be local (near the area of the initial tumor), or it may be found in distant organs.

Treatment of esophageal cancer that comes back (recurs) after initial treatment depends on where it recurs and what treatments a person has already had, as well as their health and wishes for further treatment.

Local recurrence

If the cancer was first treated endoscopically, such as with endoscopic mucosal resection (EMR) or photodynamic therapy (PDT), it most often comes back in the esophagus. This type of recurrence is often treated with surgery to remove the esophagus. If a person isn’t healthy enough for surgery, the cancer may be treated with chemotherapy, radiation, or both.

If cancer recurs locally (such as in nearby lymph nodes) after surgery, radiation and/or chemotherapy may be options. Radiation may not be an option if it was already given as part of the initial treatment. If chemotherapy was given before, it is usually still possible to give more chemotherapy. Other treatment options for local recurrence after surgery might include more surgery or other treatments to help prevent or relieve symptoms.

If the cancer recurs locally after chemoradiation or chemotherapy (without surgery), esophagectomy, surgery to remove part or all of the esophagus, might still be an option if a person is healthy enough, although the operation often comes with higher risks. If surgery is not possible, treatment options might include chemotherapy or other treatments to help prevent or relieve symptoms.

Distant recurrence

Esophageal cancer that recurs in distant parts of the body is typically treated with medicines like chemotherapy, immunotherapy, or targeted drugs (see “Treating esophageal cancer that has spread,” above).

Your options will depend on which, if any, medicines you received before the cancer came back and how long ago you received them, as well as on your health and preferences.

Recurrent cancers can often be hard to treat, so you might also want to ask your doctor if you would be eligible for clinical trials involving newer treatments.

Managing symptoms of recurrent esophageal cancer

Some people prefer not to have treatments that have serious side effects and might only choose to get treatments that will help keep them comfortable and add to their quality of life. This might include options like radiation therapy or endoscopic treatments, as well as other types of supportive care. For more on treatments that may be helpful, see Supportive Therapy for Esophageal cancer.

For more on dealing with cancer recurrence, see Understanding Recurrence.