Treatment

Treatment for esophageal cancer has improved significantly over the past several decades, with advances in imaging technology and more precise staging of the disease. Patients are now living longer and with a greater quality of life than they were just ten years ago.

Treatment will depend on the size and extent (stage) of your tumor, its location, and your overall general health. Specific treatment for esophageal cancer is done on the basis of clinical stage. Stage in individual patients is assigned according to a variety of tests, which can include upper endoscopy, endoscopic ultrasound, CT scans, PET scans, and occasionally biopsies done in Interventional Radiology (Diagnosing Esophageal Cancer, Staging the Disease).

It is most important that patients undergo appropriate initial therapy, which accentuates the importance of accurate initial staging investigations. This information is assimilated during your visit to Virginia Mason, in Seattle. Prior tests that have been done elsewhere are included in this assessment.

After all initial testing is completed, each patient’s case is presented at a weekly Thoracic Oncology Tumor Board. This meeting gathers all participating medical experts from thoracic surgery, medical oncology, radiation oncology, gastroenterology, radiology and pathology together to discuss all aspects of an individual patient's presentation, symptoms, test results, and pathologic findings. The Tumor Board issues recommendations, which are then discussed with the patient by the primary care team and the thoracic oncology nurse coordinator before a final decision for treatment is made.

Virginia Mason’s Reputation
Because Virginia Mason is a very high-volume medical center for treating esophageal cancer, our patients have survival outcomes that exceed national averages. Patients come to Virginia Mason from all over the western United States to be treated for this disease.

If Esophageal Surgery is Not an Option
Individuals who are not candidates for surgery also benefit from medical and technological advances available at Virginia Mason, including photodynamic therapy – a type of laser treatment used in conjunction with a light-sensitive drug – endoscopic stent placement, and investigational therapies offered in clinical trials.

Quality of Life
We also understand how esophageal cancer impacts our patients’ quality of life, and we are committed to helping them lead productive lives beyond their treatment. We offer extensive nutritional counseling both before and after surgery and we continually monitor our patients following surgery in an ongoing quality-of-life study.

This study, begun more than a decade ago, found that patients treated at Virginia Mason show improvements in quality of life within the first year of surgery and that 82 percent who were employed full time prior to surgery returned to their presurgical work levels. (Esophagectomy and Quality of Life)

Treatment of esophageal cancer is described below in more detail.
Nutritional Therapy

Endoscopic Mucosectomy
A mucosectomy is a procedure in which the top layer of esophageal tissue, called the mucosal layer, is removed by an endoscope. In time, another layer of tissue will grow back in its place. This procedure is often used in precancerous conditions, such as Barrett’s Esophagus.

Before the procedure, the throat is sprayed with a local anesthetic. You will be given medications through an intravenous line, which will allow you to relax and become sleepy. The endoscope is then guided into the esophagus and the area of Barrett’s is carefully examined. The specific area, or mucosa, to be removed is raised away from the wall of the esophagus by injecting sterile saline under the mucosa. This area is removed with a snare-like instrument, which is passed through the endoscope.

The procedure is performed in the Endoscopy Suite in the Gastrointestinal Unit and takes about 30-45 minutes. After the procedure there is some discomfort in the throat, which lasts for a short period of time. You will eat a soft diet for about three to four days.

Endoscopic mucosectomy was first used in clinical practice to obtain a large biopsy sample of tissue in the esophagus or colon but later evolved into a treatment modality. Unlike therapy with a laser, which destroys tissue, the specimen is preserved and can be studied further by a pathologist.

Photodynamic Therapy
Photodynamic therapy, a form of light or laser therapy, is currently being studied in clinical trials as a potential treatment for early stage cancer. It has primarily been used to restore the ability to eat in patients with established esophageal cancer who are not considered candidates for surgery.

Before treatment, patients receive an injection of a light-sensitive drug that is “taken up” in cancer cells. Laser light at the end of an endoscope is then applied to the tumor, which activates the drug and kills the cancer. The red laser light approved for use by the U.S. Food and Drug Administration (FDA) for photodynamic therapy treats cancer that is on the surface of tissue or just below it. Results can be remarkable: some patients who could not swallow solid food are able to eat a nearly normal diet within 4 to 5 days of treatment. Because of treatment with a light-sensitive drug, patients need to stay out of direct sunlight for four weeks after receiving this therapy.

Esophageal Surgery
Surgery is the most common treatment for esophageal cancer and often is curative when the cancer has not spread beyond the esophagus. Unfortunately, less than 25 percent of cancers of the esophagus are found at an early stage that allows surgery to be a curative treatment option.

There are two types of surgery for esophageal cancer: esophagectomy and esophagogastrectomy.

Esophagectomy
During this procedure, your surgeon will remove the portion of the esophagus that contains cancer along with the nearby lymph nodes. He or she will then connect the remaining portion of your esophagus to your stomach.

An esophagectomy is performed in patients with early stage disease, in which the cancer has not spread to the stomach. Patients with adenocarcinoma of the esophagus usually are not candidates for this surgery because the cancer, which occurs in the lower esophagus, may already have spread to the upper portion of the stomach.

Esophagogastrectomy
In this procedure the portion of the esophagus with cancer, the upper portion of the stomach and nearby lymph nodes are removed. The remaining portion of the stomach is then connected to the remaining portion of the esophagus. Your surgeon may first replace the part of the esophagus that was removed with a section of the large intestine before connecting it to the stomach. This procedure is called a colonic interposition.

Both operations are complicated procedures requiring 4 to 9 hours to perform. However, because Virginia Mason performs a large number of these procedures, our patients, on average, experience better outcomes and lower mortality rates than individuals treated at hospitals that do not routinely perform this surgery.

Risks associated with surgical treatment of esophageal cancer can include leaking at the surgical junction of the esophagus and stomach (or at the connection of the esophagus and colonic interposition), strictures (narrowing at the connection of the esophagus and stomach), nausea, and vomiting. Your surgeon will explain these risks in more detail prior to your surgery. With either surgery, you may be hospitalized for 1-2 weeks.

What Happens if the Cancer Comes Back

Chemotherapy
Chemotherapy is the use of powerful anti-cancer drugs that kill cancer cells by interfering with their ability to reproduce. These drugs are used to shrink the tumor and help stop the spread of the disease.

Chemotherapy for esophageal cancer may be used before or instead of surgery. Some studies show that a combination of chemotherapy and radiation therapy is more effective than chemotherapy alone in treating this disease. Clinical trials are ongoing to determine the effectiveness of chemotherapy and radiation therapy used before surgery.

Chemotherapy drugs commonly used for esophageal cancer include cisplatin and 5-fluorouracil (5-FU). Other chemotherapy drugs, such as paclitaxel (Taxol), carboplatin and CPT-11 (Irinotecan), are being investigated in clinical trials.

Typically, chemotherapy is given over a period of 3 to 6 months. The drugs are given by vein or by mouth. Often, treatments are given once every 3 to 4 weeks, which allow patients time to recover between treatment cycles.

Side effects of chemotherapy may include nausea, loss of appetite, hair loss and fatigue. More serious risks include a low white blood cell count, which may make you vulnerable to infection.

Radiation Therapy
Radiation therapy uses high-energy rays aimed at the tumor site to kill or shrink cancer cells. However, radiation therapy alone will not cure the disease. Studies have shown that, in esophageal cancer patients, radiation therapy is more effective when used in combination with chemotherapy to help shrink the tumor. Studies are ongoing to determine the role of radiation therapy when used with chemotherapy prior to surgery.

Radiation therapy may consist of treatment with an external beam of radiation focused on the cancer site, or placement of radioactive seeds, called brachytherapy, near the tumor. The seeds deliver higher doses of radiation because the radiation is not first passing through normal tissue.

At your initial consultation, your radiation oncologist will review information about your diagnosis, including the expected outcome and potential side effects. He or she may request additional tests, such as a CT scan, to help with planning.

Next, your radiation oncologist does what is called a simulation to plan your treatment. This includes x-rays, measuring, marking the location to be treated so it will align the machine with that area, and taking photos. Great care is taken to ensure accurate treatment and to safeguard your good tissue.

Usually, radiation therapy is delivered in a series of treatments over 6 to 7 weeks, on a Monday through Friday schedule. The appointments usually last 15 to 20 minutes, although the radiation treatment is only one to two minutes in length.

You may have a plastic or metal tube inserted in your throat to help keep the esophagus open prior to receiving radiation therapy. This procedure is called intraluminal intubation and dilation.

During your treatment you will be carefully monitored from outside the room. Occasionally x-ray films are taken during the procedure to make sure you are positioned accurately.

You will not feel any pain or discomfort during your treatment. After treatment, side effects may include swelling, sunburn-like changes in the treated area and possibly fatigue. Usually these changes go away in 6 to 12 months.

Palliative Treatment
Palliative therapy is intended to relieve symptoms rather than treat the disease. Patients who receive palliative treatment have cancer that is too far advanced to be treated surgically, including cancer that has spread to distant organs or lymph nodes, or have cancer that has recurred and is inoperable.

Several treatments used for palliative care are described below.

Photodynamic Therapy
Photodynamic therapy, a form of light or laser therapy, is currently being studied in clinical trials as a potential treatment for early stage cancer. It has primarily been used to restore the ability to eat in patients with established esophageal cancer who are not considered candidates for surgery.

Before treatment, patients receive an injection of a light-sensitive drug that is “taken up” in cancer cells. Laser light at the end of an endoscope is then applied to the tumor, which activates the drug and kills the cancer. The red laser light approved for use by the U.S. Food and Drug Administration (FDA) for photodynamic therapy treats cancer that is on the surface of tissue or just below it. Results can be remarkable: some patients who could not swallow solid food are able to eat a nearly normal diet within 4 to 5 days of treatment. Because of treatment with a light-sensitive drug, patients need to stay out of direct sunlight for four weeks after receiving this therapy.

Chemotherapy
Chemotherapy may be used to help shrink the tumor and control the spread of disease. Your doctor will talk to you about chemotherapy drugs used for palliative care.

Radiation therapy
Radiation therapy may be employed to help relieve pain and dysphagia (difficulty swallowing). Radiation therapy treatments may consist of either external beam radiation focused on the cancer site or placement of radioactive seeds, called brachytherapy, near the tumor.

Laser therapy
A laser, which uses high-intensity light, may be used to destroy cancer cells and help relieve blockage in the throat. Unfortunately, the results are often temporary as the cancer often comes back.

Stents
A metal stent, essentially a hollow tube made of a mesh material, may be placed in the esophagus to help keep the throat open and relieve swallowing difficulties. Placement of the stent usually is done as an outpatient procedure or with an overnight hospital stay. It offers immediate and long lasting relief for most patients.

Complications can occur, however, including movement of the stent in the esophagus, growth of the tumor causing further blockage, perforation of esophageal tissue, and bleeding.

Pain relief
Even with palliative measures, many patients experience pain because an esophageal tumor can press on nerves. Your doctor will talk to you in more detail about how to control any pain you may be experiencing. Be sure to let your doctor know if you are experiencing pain.

What Happens if the Esophageal Cancer Comes Back
In some patients treated for esophageal cancer, the disease reappears in the esophagus or elsewhere in the body. Small numbers of cells that survived the original treatment can multiply and cause cancer to recur. Your doctor will discuss treatment options with you that may be more effective for the recurrent cancer.

If initial exams and tests suggest a recurrence, a CT (computed tomography) scan, an MRI (magnetic resonance imaging), bone scans and a biopsy may be done. Depending on the location of a recurrent cancer, treatment may involve radiation therapy, chemotherapy, photodynamic therapy, or treatment on an investigational clinical study.