Esophageal Cancer Treatment

There are surgeries that can be done to treat esophageal cancer. Often surgery goes along with other treatments like chemotherapy and radiation. The amount and type of surgery depends on the stage of esophageal cancer.

Surgery can cure some patients, if the cancer is caught early. However, if the cancer has spread beyond the esophagus, surgery may not be able to remove all the cancer cells.

Esophagectomy

This surgery removes all or part of the esophagus. Many times, a small amount of the stomach is removed too. Lymph nodes are often removed as well. In the surgery, the top of the esophagus is then reattached to the stomach or small intestines. In some cases, the surgeon may replace the removed part of the esophagus with a piece of your stomach and small or large intestine.

Esophagectomies are complex surgeries. There are 2 methods:

Open esophagectomy: The main cut (incision) is in either the chest or abdomen. Sometimes there is more than one incision.

Minimally invasive esophagectomy: If the cancer is caught early and is small, the surgeon can remove the esophagus through several small incisions (cuts). The surgeon uses a scope (like a tiny telescope) to see everything during the operation. Then long, thin surgical instruments go in through other small incisions. A minimally invasive esophagectomy lets you leave the hospital sooner. Recovery time is also shorter.

When removing some or the entire esophagus, the surgeon will also take out nearby lymph nodes. These lymph nodes will be checked for cancer cells.

What to Expect

It is important to discuss risks and possible complications prior to undergoing surgery. Common risks include:

• The stomach empties too slowly which can cause nausea and vomiting.
• A leak may develop where the stomach meets the esophagus, requiring further treatment.
• Narrowing of the esophagus, causing difficulty swallowing
• Heartburn

Keep in mind that esophageal surgery can be very complex.

Chemotherapy treatment (usually called “chemo”) is the use of drugs that prevent cancer cells from growing and spreading. Chemotherapy medicines either destroy cancer cells altogether or stop them from dividing. Chemo affects your whole body because it goes through your bloodstream. Chemo doesn’t refer to one treatment but many, because there are lots of different chemotherapy medicines.

When is chemotherapy used?

Chemo can be used in several ways:

• As the main treatment
• Neoadjuvant: Before surgery to shrink the cancer
• Adjuvant: After the cancer has been removed by surgery. This treatment is used to try to kill any tumor cells that were too small to be seen and may have been left behind, or if there is lymph node involvement.
• Palliative treatment: Alone or with radiation to help control symptoms like pain or trouble swallowing when the cancer can't be cured.

Chemo can often shrink tumors that cause pain, pressure, and difficulty swallowing. Often chemo is combined with radiation or surgery.

When given alone, chemo is given in a higher dose designed to kill off cancer cells. When given along with radiation therapy, it is delivered at a lower dose. This is designed to make the cancer more sensitive to the radiation.

Chemotherapy is usually given by vein, but some forms can be given by mouth. Your medical oncologist will tell you how many cycles or courses of chemotherapy are best for you.

The number of cycles of chemotherapy needed vary.

Different oncologists use different schedules. Treatment schedules can vary depending on the type of drug being used.

What can I expect from chemotherapy?

Chemotherapy not only weakens and destroys cancer cells at the site of the tumor, but throughout the body as well. Unfortunately, this means that chemo can unintentionally harm the development of normal cells like your hair, nails, mouth, and digestive tract.

The side effects chemo causes depend on the type of chemotherapy you receive and how many cycles you receive. The most common side effects of chemo are:

• Nausea and vomiting
• Fatigue or tiredness
• Confusion, forgetfulness (“chemo brain”)
• Decreased blood counts, sometimes causing bruising, bleeding and/or infection
• Sores inside your mouth
• Numbness in your hands and feet (peripheral neuropathy)
• Diarrhea, loose stool
• Increased urgency to have a bowel movement or urinate

When chemotherapy is given at a lower dose, these side effects are usually less common. If you experience side effects, call your physician right away. It is better to address side effects right away. There are numerous drugs available to help manage side effects.

Most side effects go away once treatment is over. Patients with continued side effects should talk with their doctor or nurse, as there are often ways to help.

Patients with esophageal cancer often have trouble eating, swallowing and/or problems with weight loss before the cancer is even found.  Chemo can cause painful sores in the mouth and throat, which can make it difficult to eat and maintain good nutrition. Some patients with esophageal cancer need to have a feeding tube put in, usually during an outpatient procedure. This allows liquid "food" to be put right into the intestine. A feeding tube can help prevent further weight loss.

How is chemotherapy given?

Chemo medicines come in different forms and can be given in different ways:

Intravenously (IV): As an infusion, the medicine comes through a thin needle (IV) in a vein, such as in your hand or lower arm. An oncology nurse will insert the needle before each infusion and take it out afterwards. Inform your nurse if you experience any burning, redness, or irritation while receiving chemo.

• Injection: As a single shot into a muscle in your leg, arm, hip, or under the skin in the fatty part of your stomach, leg or arm.
• Orally: As a pill or capsule or liquid. You may take this yourself at home.
• Port: This is inserted in your chest during a short outpatient surgery. It is about the size of a quarter and sits right under your skin. A port is a small disc made of plastic or metal. A catheter (soft thin tube) connects the port to a large vein. The chemo medicines are delivered through a thin needle right into the port. You can also get your blood drawn through the port. Once you have finished chemo, the port is removed in a brief outpatient procedure.
• Through a catheter in your chest or arm. This is a soft thin tube that is inserted into a large vein. This is done in a short outpatient surgery. The other end of the catheter stays outside your body. This is similar to having a port.

If you have a catheter or port, your medical team will educate you about the signs of infection.

What’s the advantage to a port or catheter?

Many doctors recommend getting a catheter or port. Some esophageal cancer patients have a portable pump attached to the port or catheter. This controls the amount and how fast the chemotherapy medicine is infused. The pump can either be internal (implanted under the skin during a short outpatient procedure) or external (carried with you). After completion of chemo the pump will be removed.

How often will I receive chemotherapy?

Your oncologist will set your treatment regimen. Every chemo regimen is made up of cycles. This means a period of treatment followed by a period of recovery. For example, you may receive chemo one day and then have a few weeks of recovery with no treatment. This is defined as one cycle. Or you may get chemo for several days in a row and then have a recovery period. Several cycles make up a complete chemotherapy regimen.

The number of cycles in a regimen and the length of each regimen vary from patient to patient. A lot depends on the medicines used.

You can receive chemotherapy in a variety of settings a hospital, a doctor’s office, or an infusion clinic. You may even receive chemo at home if you are taking chemo in a pill form or you have a portable pump.

If you take chemo in a clinic, hospital or doctor’s office, you usually go home between treatments. In some cases, you may stay in the hospital to be monitored. This is especially true if your immune system isn’t working as well as it should. Your doctor will explain where you’ll be getting your treatment and monitoring your care throughout your treatment.

Passing Time During Chemo

A chemotherapy treatment at a hospital or clinic can take anywhere from one to several hours. Although many chemo treatment areas have televisions and magazines, you may want to bring something to help pass the time. Ideas include:

• A laptop
• Knitting, needlepoint or crochet
• A thick novel
• Crossword or other puzzle book
• Sketchbook and pencils
• Cards or board games (if you have someone to play with)
• MP3 or portable CD player to listen to music
• Paper and pens to keep a journal or write letters
• Pillow and blanket

Is there anything I should do before I start chemotherapy?

Chemotherapy treatment can drain most of your energy. There are some things you should take care of before you start chemo:

• You may be asked to take medication prior to arriving. Check with your nurse navigator or physician.
• Get your teeth cleaned and get a complete dental check-up. Chemo weakens your immune system, so you may be more vulnerable to infections caused by bacteria that are dislodged during teeth cleaning.
• Get any heart tests (like an EKG) that your doctor recommends.
• Females are advised to get a routine pap smear before chemo. Chemo can alter the results of a Pap smear, so get one beforehand.
• Find someone to help around the house. Chemo causes extreme fatigue. Line up someone to help with your daily chores: cleaning, grocery shopping, carpooling, and cooking to name a few. Don’t be too proud or stoic to ask for help. Friends and family members will be happy to do something that helps you during this treatment phase. Ask yourself: wouldn’t you be willing to do it for someone else?
• Join a support group if that sounds helpful.
• Find out ahead of time what you should and shouldn’t eat or drink on treatment days.
• Tell your doctor all the vitamins, supplements, over-the-counter and prescription medicines you take.
• Talk to your doctor about hair loss. Most chemo medicines cause some amount of hair loss. If you plan on wearing a wig, you might want to go ahead and get it so you can match it to your hair color and style.

Radiation treatment (usually just called radiation) uses high energy rays (such as X-rays). There are 2 purposes:

• To destroy cancer cells or
• To shrink tumors.

External radiation is the type of radiation most often used for esophageal cancer. It uses a beam from outside your body.

For internal or implant radiation, a radioactive source is temporarily placed in a tube inside the esophagus right up against the tumor. This method is typically used with more advanced esophageal cancers. The internal radiation reduces the tumor size so you can swallow more easily. This approach is often used as a way to relieve symptoms, not cure the cancer.

Side effects of radiation to the esophagus may include:

• Redness and tenderness to the skin
• Nausea and vomiting
• Fatigue

Often these side effects go away when treatment ends. Your doctor may be able to give you some medication to make you more comfortable during treatment.

In addition to surgery, radiation, and chemotherapy, there are also additional treatment options for esophageal cancer.

Endoscopic mucosal resection

In endoscopic mucosal resection (EMR), the inner lining of your esophagus is removed. EMR is often used for pre-cancer or cell changes. These are called dysplasia. EMR can be used for very early, small tumors of your esophagus. After you have this procedure, you will be given a medication that reduces stomach acid. This helps keep the cancer from returning.

PDT (photodynamic therapy)

If the cancer is found very early, PDT is an option. In this treatment, a harmless chemical is put into your bloodstream. This collects in the tumor for a few days. Then the doctor focuses a special laser light on the cancer through an endoscope. This light activates the chemical so it can destroy the cancer cells. The advantage of PDT is that it does not hurt normal cells. PDF does not work for cancers that have spread deeper or beyond the esophagus.

Side effects of PDT can include:

• Swelling of the esophagus
• Problems swallowing
• Redness of the skin
• Sensitivity to sun

These side effects are usually temporary. If you have PDT, you will probably have to stay indoors for about 6 weeks because of sun sensitivity.

PDF is also used to relieve symptoms of advanced cancer.

Radiofrequency ablation (RFA)

This is used to treat Barrett’s Esophagus. This is a pre-cancerous condition in which the lining of your esophagus is damaged by stomach acid. In radiofrequency ablation, your doctor passes a balloon into an area of your esophagus. The balloon is inflated so that the balloon surface touches the inner lining of your esophagus. High-power energy travels through the balloon to kill the cells in the lining. Normal cells will then grow to replace the Barrett’s cells. You will need to take medications that keep your stomach from making too much acid after you’ve had this treatment. Your doctor will want to do routine endoscopies in the future to watch for changes to the lining of your esophagus.

Laser ablation

In laser ablation, an endoscope uses a laser to destroy cancer cells. Laser ablation can also open up your esophagus when it is blocked. This helps relieve swallowing problems. This treatment may need to be done every couple of months, because the cancer often grows back.

Electrocoagulation

This method burns the tumor off with electric current. This can help relieve blockage.

Esophageal stent

This device is made of mesh. Using endoscopy, a stent is placed into your esophagus. Once there, it opens up to become a tube that helps hold your esophagus open. Stents can relieve problems swallowing.