Treatment of esophageal cancer is decided by the stage, by the histological type and by whether the patient can withstand major surgery. Because the disease is usually found late, cure is realistic mainly for tumors that are still confined to the esophageal wall; for everyone else, the aim shifts towards controlling the disease and relieving symptoms.
Superficial disease
Tumors limited to the mucosa, Tis and T1a, can often be removed endoscopically without an operation. Endoscopic resection treats the lesion and at the same time provides a specimen to confirm how deep it has gone, and it gives high cure rates for genuinely superficial cancer. Once the tumor has reached the submucosa (T1b) or deeper, or lymph nodes are involved, the risk of nodal spread is high enough that surgical removal of the esophagus is needed instead.
Locally advanced, resectable disease
For tumors that have grown beyond the mucosa but can still be removed, surgery alone is no longer the standard. Giving chemotherapy and radiotherapy before the operation improves survival and reduces recurrence compared with surgery alone, so combined treatment followed by surgery is the usual approach. In adenocarcinoma of the esophagus and gastroesophageal junction, perioperative chemotherapy — given before and after surgery — is an alternative; modern regimens such as FLOT (fluorouracil, leucovorin, oxaliplatin and docetaxel) have improved survival over older combinations. After surgery, patients whose resected specimen still contains residual tumor despite preoperative chemoradiotherapy may be offered adjuvant immunotherapy with nivolumab, which prolongs the time to recurrence.
Unresectable or inoperable disease
When the tumor cannot be removed, or the patient is not fit for surgery, definitive chemoradiotherapy is the main option. For squamous cell carcinoma, definitive chemoradiotherapy can give outcomes similar to surgery, which is why it is a reasonable choice rather than a compromise. Radiotherapy given alone is less effective than chemoradiotherapy.
Advanced and metastatic disease
Metastatic esophageal cancer is treated to control symptoms and prolong survival rather than to cure. The backbone is systemic chemotherapy, and adding an immune checkpoint inhibitor to first-line chemotherapy now improves survival for both squamous cell carcinoma and adenocarcinoma. Adenocarcinoma that is HER2-positive can also receive HER2-directed therapy such as trastuzumab alongside chemotherapy.
Relieving dysphagia
Many patients need relief of dysphagia and support with nutrition. A self-expandable metal stent placed endoscopically is the recommended way to palliate the obstruction, and laser therapy, photodynamic therapy or electrocoagulation can destroy tumor growing within the lumen. When the esophagus is completely blocked and there is no evidence of widespread metastasis, surgical removal of the tumor with the stomach mobilized to replace the esophagus remains an option.