Esophageal Cancer Treatment Options

• Endoscopic Mucosal Resection (EMR) — high probability candidate
• Photodynamic therapy
• Laser surgery
• Radiofrequency ablation
• Electrocoagulation and argon plasma coagulation
• Palliative endoscopic treatments and procedure

Most people with esophageal cancer get chemotherapy. See below for a closer look at chemotherapy.

Surgery is the option in which all or part of the esophagus is removed, called an esophagectomy.  Often surgery is not the first approach to treatment, unless the esophageal tumor is limited to the esophagus.  Even then, surgery may be preceded by chemotherapy and/or radiation treatments to kill as many tumor cells as possible before the surgery.  Chemotherapy and irradiation may follow surgery in some cases, as insurance that no tumor cells remain.

There are several types of surgery for esophageal cancer
The type depends mainly on where the cancer is located. The surgeon may remove the whole esophagus or only the part that has the cancer . Usually, the surgeon removes the section of the esophagus with the cancer, lymph nodes, and nearby soft tissues. Part or all of the stomach may also be removed. You and your surgeon can talk about the types of surgery and which may be right for you.

The surgeon makes incisions into your chest and abdomen to remove the cancer. In most cases, the surgeon pulls up the stomach and joins it to the remaining part of the esophagus. Or a piece of intestine may be used to connect the stomach to the remaining part of the esophagus. The surgeon may use either a piece of small intestine or large intestine. If the stomach was removed, a piece of intestine is used to join the remaining part of the esophagus to the small intestine.

What Happens during Surgery?
During surgery, the surgeon may place a feeding tube into your small intestine. This tube helps you get enough nutrition while you heal.

You may have pain for the first few days after surgery . However, medicine will help control the pain. Before surgery, you should discuss the plan for pain relief with your health care team. After surgery, your team can adjust the plan if you need more relief . Your health care team will watch for signs of food leaking from the newly joined parts of your digestive tract. They will also watch for pneumonia or other infections, breathing problems, bleeding, or other problems that may require treatment.

The time it takes to heal after surgery is different for everyone and depends on the type of surgery. You may be in the hospital for at least one week.

Most people with Esophageal Cancer get chemotherapy.

Chemotherapy uses drugs to destroy cancer cells. The drugs for Esophageal Cancer are usually given through a vein (intravenous). You may have your treatment in a clinic, at the doctor’s office, or at home . Some people need to stay in the hospital for treatment.

Chemotherapy is usually given in cycles. Each cycle has a treatment period followed by a rest period .

The side effects

Side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drug can also harm normal cells that divide rapidly:

Blood cells

When chemotherapy lowers the levels of healthy blood cells, you’re more likely to get infections, bruise or bleed easily, and feel very weak and tired . Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of drug . There also are medicines that can help your body make new blood cells.

Cells in hair roots

Chemotherapy may cause hair loss. This doesn’t happen to everyone. If you lose your hair, it will grow back, but it may change in color and texture.

Cells that line the digestive tract

Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems.

Other possible side effects

Include a skin rash, joint pain, tingling or numbness in your hands and feet, hearing problems, or swollen feet or legs . Your health care team can suggest ways to control many of these problems. Most go away when treatment ends.

Radiation therapy may be used before or after surgery or it may be used instead of surgery. Radiation therapy is usually given with chemotherapy to treat esophageal cancer. Doctors use two types of radiation therapy to treat esophageal cancer. Some people receive both types:

External radiation therapy

The radiation comes from a large machine outside the body. The machine aims radiation at your cancer . You may go to a hospital or clinic for treatment. Treatments are usually 5 days a week for several weeks.

Internal radiation therapy (brachytherapy)

The doctor numbs your throat with an anesthetic spray and gives you medicine to help you relax . The doctor puts a tube into your esophagus. The radiation comes from the tube. Once the tube is removed, no radioactivity is left in your body. Usually, only a single treatment is done

Side effects

Side effects depend mainly on the dose and type of radiation. External radiation therapy to the chest and abdomen may cause a sore throat or pain similar to heartburn, or pain in the stomach or the intestine. You may have nausea and diarrhea. Your health care team can give you medicines to prevent or control these problems.

Also, your skin in the treated area may become red, dry, and tender . You may lose hair in the treated area. A much less common side effect of radiation therapy aimed at the chest is harm to the lung, heart, or spinal cord.

You are likely to be very tired during radiation therapy, especially in the later weeks of external radiation therapy. You may also continue to feel very tired for a few weeks after radiation therapy is completed. Resting is important, but doctors usually advise patients to try to stay as active as they can.

Radiation therapy can lead to problems with swallowing . For example, sometimes radiation therapy can harm the esophagus and make it painful for you to swallow. Or, the radiation may cause the esophagus to narrow. Before radiation therapy, a plastic tube may be inserted into the esophagus to keep it open. If radiation therapy leads to a problem with swallowing, it may be hard to eat well. Ask your health care team for help getting good nutrition.

5 Immunotherapies are in regular use

Checkpoint Inhibitors/ Immune Modulators:
A promising avenue of clinical research in esophageal cancer is the use of immune checkpoint inhibitors. These treatments work by targeting molecules that serve as checks and balances in the regulation of immune responses. By blocking inhibitory molecules or, alternatively, activating stimulatory molecules, these treatments are designed to unleash or enhance pre-existing anti-cancer immune responses . Several checkpoint inhibitors, targeting multiple different checkpoints, are currently in development.

Adoptive Cell Therapy (ACT):
Another major avenue of immunotherapy for esophageal cancer is adoptive T cell transfer. Here, T cells are removed from a patient, genetically modified or treated with chemicals to enhance their activity, and then re-introduced into the patient with the goal of improving the immune system’s anti-cancer response . Several trials of adoptive T cell transfer techniques are currently under way for patients with esophageal cancer.

Monoclonal Antibodies (mAbs):
mAbs are molecules, generated in the lab, that target specific antigens on tumors. Many mAbs are currently used in cancer treatment, and some appear to generate an immune response. Several mAbs are currently being tested in clinical trials .

Therapeutic Vaccines:
Cancer vaccines are designed to elicit an immune response against tumor-specific or tumor-associated antigens, encouraging the immune system to attack cancer cells bearing these antigens.

Cytokines:
Cytokines are messenger molecules that help control the growth and activity of immune system cells.

Photodynamic Therapy (PDT) may be used to treat the early stages of esophageal cancer.  Chemicals that are sensitive to certain wavelengths of light are injected into the bloodstream and are taken up by the body’s cells. Abnormal cells take up more than normal cells. After a period of sensitization, a light source is focused upon the area containing the abnormal cells. The light causes the chemical to react inside of these cells, killing them.

There are other less common treatment approaches available, as well as many new therapies and many new clinical trials now being tested . It is not possible to list all of the ways that esophageal cancer may be treated. Esophageal cancer patients should have thorough discussions of treatment possibilities with their physicians to learn their options for treatment, given their stage of esophageal cancer and whether or not metastatic tumors are present.

Clinical trials are experimental & beyond the commonly accepted
The treatment should have already passed a number of tests to be tested clinically, but is still awaiting approval by the governing health authority. In the US, those authorities are primarily the Food & Drug Administration and the Department of Health & Human Services.

Doctors all over the country are conducting many types of clinical trials (research studies in which people volunteer to take part). Clinical trials are designed to answer important questions and to find out whether new approaches are safe and effective.

Check out the NCI’s Clinical Trials directory.