Esophageal Cancer Treatment Options

Esophageal cancer treatment depends on three things. Those are the stage, the cell type, and where the tumor sits. Squamous cell carcinoma and adenocarcinoma are treated somewhat differently. A tumor near the top of the esophagus is treated differently than one near the stomach. Your team also weighs your overall health. Some of these treatments are demanding. Most people get more than one type of treatment, not just one.

Some esophageal cancers are found very early. At this point, the cancer is still confined to the inner lining. Doctors can sometimes remove these through an endoscope. That is a thin tube passed down the throat. No open surgery is needed. This is called endoscopic mucosal resection, or endoscopic submucosal dissection for a deeper cut. Another tool, radiofrequency ablation, uses heat to destroy abnormal tissue in the lining. These options avoid a major operation. They only work when cancer has not grown deep or spread.

Surgery is often central to the plan for cancer that has grown deeper but has not spread far. The operation is called an esophagectomy. A surgeon removes the part of the esophagus with the tumor. Nearby lymph nodes come out too. The remaining esophagus is then reconnected. Surgeons usually pull up part of the stomach to rebuild a passage for food. This is a major operation. Recovery takes weeks. Your team will explain what to expect for eating, digestion, and daily life afterward.

Sometimes cancer has grown into deeper layers or reached nearby lymph nodes, but has not spread to distant organs. Doctors usually treat this with more than surgery alone. Chemotherapy and radiation are often given together first. Doctors call this chemoradiation. It shrinks the tumor before the operation. It also kills stray cancer cells nearby. Doctors call this step neoadjuvant treatment, meaning it comes before the main treatment. Surgery follows several weeks later. Combining these steps improves the chance of removing all the cancer.

Sometimes a small amount of cancer remains in the tissue removed during surgery. When that happens, the FDA has approved an immunotherapy drug called nivolumab as an added treatment. It is given for up to a year. It lowers the chance the cancer returns. This applies to people who had chemoradiation before surgery and still had some cancer left afterward.

Some tumors cannot be safely removed by surgery. This can be due to their location or size. It can also be due to a person's overall health. In that situation, chemoradiation alone can become the main treatment. The goal shifts to controlling the cancer for as long as possible, rather than removing it.

Once esophageal cancer has spread to distant organs, removing the tumor is no longer the goal. Treatment shifts to drugs that travel through the bloodstream. These drugs reach cancer cells wherever they are.

Chemotherapy is usually the backbone of this treatment. For many people, doctors now add immunotherapy. Drugs like pembrolizumab or nivolumab block a protein called PD-1. Cancer cells use PD-1 to hide from the immune system. Blocking it helps the immune system attack the tumor.

Tumor testing also guides treatment. Somewhere between about 8 and 20 in 100 gastroesophageal adenocarcinomas make too much of a protein called HER2, and it is more common near the junction with the stomach. If your tumor tests positive for HER2, you may be offered a targeted drug called trastuzumab. The FDA has also approved pembrolizumab with trastuzumab and chemotherapy for advanced HER2-positive gastric or gastroesophageal junction adenocarcinoma whose tumors also express PD-L1. That is why testing comes before treatment, not after.

Treatment can still ease symptoms and improve daily life, even when a cure is not possible. A stent is a small expandable tube. Doctors can place one inside the esophagus to hold it open. This helps when a tumor is narrowing it and making swallowing hard. Radiation can also shrink a tumor enough to ease pain or swallowing trouble. A feeding tube may help if eating enough by mouth becomes difficult. This is not a lesser form of care. It is care aimed at comfort and function. It can be combined with cancer-directed treatment too.

• What is the stage and cell type of my cancer, and how does that shape my plan?
• Will I have chemotherapy or radiation before surgery, after it, or both?
• Has my tumor been tested for HER2, and would that change my options?
• If a cure is not the goal, what can be done to help me eat and feel better?
• What does recovery from surgery actually look like, day to day?
• Is a clinical trial a reasonable option for me?

• National Cancer Institute — Esophageal Cancer Treatment (PDQ) Patient Version
• American Cancer Society — Treatment of Esophagus Cancer
• FDA — Approval of Opdivo (nivolumab) for resected esophageal or gastroesophageal junction cancer with residual disease
• Biomarkers in gastroesophageal cancer (PMC)
• FDA — Pembrolizumab with trastuzumab and chemotherapy for HER2-positive gastric or gastroesophageal junction adenocarcinoma