Therapy is based on the type of esophageal cancer (adenocarcinoma or squamous cell carcinoma), location, stage, and prognosis. It's critical to know the stage of disease. Staging occurs during diagnosis, and ranges from early-stage disease to stage IV esophageal cancer, which means the cancer cells have already spread to distant sites in the body. Additional tests may be used during the staging process, such as the endoscopic ultrasound.
Some patients' cases are discussed at a multidisciplinary tumor board — a conference attended by many doctors with different specialties that might be required for your care.
Five main types of treatment are used for esophageal cancer: surgery, radiation, chemotherapy, targeted therapy, and endoscopic treatments.
This is the most common treatment used for esophageal cancer, and the procedure is generally known as an esophagectomy. Surgeons remove most or part of the esophagus and often part of the stomach, and then reconnect the remaining healthy esophagus to the healthy stomach. The operation has a few different approaches — for example, for early-stage cancer there is a minimally invasive esophagectomy — but the standard technique requires one or more large incisions in the neck, chest, or abdomen. In cases of advanced cancer, surgeons might also be able to relieve symptoms or improve quality of life. For example, a feeding tube can be placed into the abdomen to allow patients to receive essential nutrients.
Esophagectomy is not a simple operation and can result in life-threatening side effects such as pneumonia and leaking content from the intestines. It's important to have this operation done at a hospital with a lot of experience — and Wilmot Cancer Institute performs more esophagectomies than any other cancer center in upstate New York.
In addition, Wilmot oncologists frequently recommend that chemotherapy or radiation is given before an esophagectomy to shrink the cancer and improve the chances the surgeon will be able to remove it all. This is an approach with proven success that not all cancer centers offer.
Radiation therapy uses energy from radiation beams, radio isotopes, or charged particles to target tumors and eradicate cancer cells. Radiation for esophageal cancer is used before surgery to shrink tumors, after surgery to kill remnants of the cancer, or in combination with chemotherapy. It can also be used in advanced cases of esophageal cancer to control bleeding or ease pain. If the goal is to cure esophageal cancer, external beam radiation is most common. In more advanced cases, doctors can place radioactive materials through an endoscope and drop them very close to the cancer to try and shrink the tumor and relieve symptoms.
Chemotherapy uses drugs or combinations of drugs — given intravenously or as pills — to destroy cancer cells. Chemo can be given before or after surgery, alone or with radiation, or as the primary treatment is a patient is not eligible for surgery.
These are newer drugs designed to target specific gene changes that result in esophageal cancer. They single out cancer cells without harming normal cells and tend to have less severe side effects compared to chemotherapy. Some esophageal cancers have too much of a protein called HER2/neu on the surface of cells. (The same protein is present is some breast and stomach cancers.) Herceptin is an example of a targeted therapy that attacks the HER2 protein. Other drugs that target HER2 are being studied.
Another drug, Cyramza, which can be used for esophageal or stomach cancer, is a targeted therapy known as a monoclonal antibody. It attacks proteins responsible for the growth of blood vessels that feed esophageal cancer cells.
These involve placing an endoscope down the throat into the esophagus to destroy cancer or relieve symptoms. This therapy is usually offered when tumors are smaller or early-stage.
Possible endoscopic treatments include:
- Endoscopic mucosal resection (EMR), in which the surgeon removes a part of the inner lining of the esophagus when pre-cancerous tissue or very early stage cancer is suspected. Afterward, the patient takes drugs called proton-pump inhibitors to suppress stomach acids and keep the disease from returning.
- Photodynamic therapy (PDT) to treat Barrett's esophagus, early-stage disease, or large cancers that block the esophagus. It can only be used when the cancer is near the inner surface of the esophagus and can be detected by light. Doctors inject a light-sensitive drug that finds cancer cells, and then use an endoscopy to focus a special laser light on the lit-up cancer cells and destroy them. This procedure requires follow-up endoscopies.
- Radiofrequency ablation (RFA) to treat Barrett's esophagus. Doctors pass a balloon containing small electrodes through an endoscope to the target area, and by heating up the tissue the pre-cancerous cells are destroyed.
- Laser ablation or argon plasma coagulation for advanced cancer. A laser beam or argon gasses emitted from the tip of an endoscope is aimed at tumors with the goal of opening a blocked esophagus. Laser ablation is often repeated if the cancer grows back.
- Electrocoagulation, which is also used to relieve a blocked esophagus. A probe with an electric current is passed through the endoscope to burn off the tumor.
- Esophageal stent. Doctors use an endoscope to place a stent that will hold open the esophagus after other endoscopic treatments and to relieve trouble swallowing.
Many cancer treatments cause side effects such as hair loss or fatigue, but not everyone experiences side effects the same way.
The American Cancer Society also offers a free online class to help patients manage the side effects of their illness.