The patient with a diagnosis of esophageal cancer will go through a complicated treatment process. There is no single method of treatment for esophageal cancer as there is for other types of cancer. Instead, the people with this type of cancer are treated in several ways, depending on the type, stage, and location of the cancer as well as the patient’s overall health. The aim of the treatment is to control cancer, relieve symptoms and to achieve the best possible quality of life.
So the treatment for esophageal cancer is often given in a number of stages, sometimes adding further treatment after some time as the cancer develops. Thus, esophageal cancer treatment is a complex process of different steps of treatment.
Starting With Diagnosis and Staging
Esophageal Cancer Treatment starts with a diagnosis of the type of cancer and the stage where it is at. A diagnosis is made after a biopsy is taken to check for cancer cells in the sample of tissue. After cancer cells have been identified as cancerous, results from other tests can tell where the primary tumor is and the stage of the cancer.
There are two main types of histological types of esophageal cancer: esophageal squamous cell carcinoma and adenocarcinoma. These two types of cancer have distinct biological behavior and typically occur in different parts of the esophagus.
Early-stage cancer can be treated by removing the tumor tissues by endoscopy or by surgery. The goal of treatment for stage I cancer is to remove all cancerous tissues. Patients with stage I cancer can be treated by surgery alone, or by a combination of chemotherapy and/or radiation therapy followed by surgery.
Treatment for Earlier-Stage Disease
For very early stage of cancers, especially with small number of cancer cells, strategy to treat them as to remove abnormal tissues including cancers/dysplasia’s as a cure by endoscopic resection (EMR) and/or by surgery. Patients with high grade dysplasia’s (pre-cancer) can also be treated in this manner.
Treatment for Stage I cancers can involve a number of different approaches, depending on the individual case. Some Stage I cancers are treated with surgery alone, while others are given chemoradiation before surgery. The decision about the best course of treatment is based on a number of factors, including the type of cancer, and the individual’s circumstances.
Immunotherapy as a component of treatment for patients with esophageal cancer.
When Surgery Becomes Part of Treatment
Surgery for esophageal cancer is in the form of an esophagectomy where part of the esophagus is removed. The remaining part of the esophagus is then connected to the stomach or to another part of the digestive system which has been re-constructed. Lymph nodes near the esophagus are also removed during the operation.
Surgery for the treatment of esophageal cancer is not a treatment for every patient with esophageal cancer. To consider esophageal cancer for possible treatment by surgery, several important factors must be taken into account. These factors include the location of the primary tumor, the stage of the primary tumor, the overall medical condition of the patient, and whether or not all the cancer can be completely removed from the patient’s esophagus during the proposed surgical procedure.
For locally advanced esophageal cancer, a combination of treatment methods can be used. Some patients are given a course of chemotherapy before surgery, while others are treated with chemoradiation before surgery. The aim of this pre-surgical treatment is to reduce the size of the tumor and to ensure that the cancer can be completely removed during surgery.
The Role of Chemotherapy and Radiation
Chemotherapy: Anti-cancer drugs that travel through the bloodstream to kill cancer cells. Since cancer often has spread to other parts of the body, these drugs can be effective in treating tumors in other parts of the body as well as the primary tumor.
External radiation therapy delivers radiation from outside the body. Internal radiation therapy, on the other hand, places the radiation right inside the patient.
Chemotherapy, radiation therapy, and a combination of the two as definitive treatment, as neoadjuvant treatment before surgery, and as part of overall treatment strategy.
Importantly, a single treatment pathway will not apply in all cases.
Where Immunotherapy Fits
Immunotherapy is increasingly playing a role in the treatment of patients with advanced or recurrent esophageal cancer. These agents interact with immune checkpoint proteins to inhibit the normal function of these proteins and allow T cells to more effectively fight cancer.
Nivolumab (Opdivo) is a PD-1 inhibitor that has been approved by the FDA for the treatment of advanced or recurrent squamous cell carcinoma of the esophagus and for the treatment of advanced or recurrent adenocarcinoma of the esophagus. These patients must have received prior chemoradiation and undergone surgery for their cancer, but have residual cancer in the surgical specimen.
In some instances of advanced or recurrent disease, chemotherapy is used in conjunction with immunotherapy. This is in specific circumstances (e.g. advanced disease) and based on a number of parameters including the type of cancer, the stage of the disease, previous treatment(s), as well as a number of biomarkers.
Understanding Biomarkers and Tumor Characteristics
Biomarkers are increasingly used for selecting patients with cancer for best possible treatment using targeted or immune-based therapies. In the majority of cases tumors are analyzed for presence of biomarkers that select the best possible treatment for an individual patient.
The biomarker PD-L1 can be used as a predictor for response to certain immunotherapies. However, The use of immunotherapies based on the biomarker PD-L1 expressed on the surface of tumors depends on a variety of factors, including the type of cancer, prior treatment of the cancer, the test or assay used to measure the expression of PD-L1 on the surface of cancer cells, as well as the approved indication for use of the immunotherapy. Therefore, results from biomarker testing must be interpreted in the context of the patient’s clinical situation.
Targeted therapy: These are drugs which target specific proteins or specific molecular events that are involved in cancer cells’ growth, division, etc.
Managing Symptoms During Treatment
In addition to treating the primary tumor, a patient with cancer in the esophagus can have symptoms caused by the tumor in the esophagus. In addition, some treatments for cancer in the esophagus can cause a patient to have problems with eating. Thus, in treating patients with cancer in the esophagus, it is also necessary to meet their nutritional needs. Some patients require additional nutritional support in the form of a feeding tubes or intravenous hyperalimentation.
For growing esophageal cancer tumors in the esophagus, symptoms of growing tumors in the esophagus, such as difficulty swallowing (dysphagia) can occur. If there is a single tumor or a group of tumors growing in the esophagus and they are blocking the esophagus (partially or completely) and/or the food passage to the stomach, relief of these symptoms may be necessary. Relief of these symptoms can be achieved by placing an expandable stent through the tumor(s) in the esophagus. Relief of these symptoms can also be achieved by other methods of relieving symptoms such as radiation therapy, laser therapy and methods of using electrocoagulation.
Stenting, laser treatment, and other forms of palliation can be used to relieve symptoms in patients with advanced and/or recurrent esophageal cancer.
Treatment for Advanced or Recurrent Disease
For patients with advanced or recurrent esophageal cancer, the goal of treatment is to control tumor growth and relieve symptoms to allow patients the best quality of life. There are several different treatment options including systemic chemotherapy, immunotherapy, chemoimmunotherapy, targeted therapy for specific genes, radiation therapy with radiation, and supportive and palliative care.
The consideration of previous treatment(s) for recurrent disease and of other potential treatments including a clinical trial, can be of value to patients in specific situations.
Managing Side Effects and Quality of Life
Side effects of treatment vary from treatment to affect different people in different ways. For example the side effects of surgery to the esophagus can result in swallowing problems and eating difficulties. Some side effects of chemotherapy and radiotherapy can result in fatigue. The side effects of immunotherapy can be due to an over active immune system affecting normal tissues.
Supportive care and symptom control is also an essential component of a holistic approach to the care and support of individuals with esophageal cancer and their families. The following are examples of support that can be offered to individuals with esophageal cancer during treatment for their cancer:
Why Treatment Is Increasingly Individualized
Of course, the treating doctor will develop a strategy for his or her patients. The sequence of individual treatments can change during the course of treatment.
Furthermore, many trials are currently conducted to test new single agents or combinations of drugs, such as immunotherapeutic approaches or targeted therapies. Some of these new treatments might even offer greater benefits than the established standards.
Looking Beyond a Single Treatment
Because of the many factors involved in the treatment of cancer, each patient with cancer will have his/her own individual plan of treatment. In addition to assessment for potential treatment, the individual with cancer and/or his/her family will want to know what to expect and how he/she will feel during and after his/her treatment for cancer.
The reader will understand why the same treatment is not always given for the same type of cancer and why the cancer team may consider giving different treatments at different points in the management of a patient’s cancer.
As more information about the molecular characteristics of tumors is gathered by future cancer research, more novel cancer treatments, for example of esophageal cancer, will be developed. In addition to various types of treatment, like immunotherapy, as well as different types of targeted therapies for cancer, which are already currently used for the treatment of cancer, there will be a wide array of different combinations of treatments for cancer, in order to treat cancer in the best possible manner and to allow patients with cancer and their families the greatest amount of time and the best possible quality of life, and to continue to seek the advice and counsel of a multidisciplinary team of cancer experts.
Disclaimer: The information provided in this article is intended for educational purposes only and should not be interpreted as medical advice, a clinical guideline, or a recommendation for any specific treatment. Consult Healthcare professionals for full prescribing information, peer-reviewed literature, and current national and international clinical guidelines before making treatment decisions. Patients should seek advice from their haematologist, oncologist, or other qualified healthcare professionals regarding diagnosis and treatment options.
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