Esophageal Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Treatment Option Overview
The prevalence of Barrett metaplasia in adenocarcinoma of the esophagus suggests that Barrett esophagus is a premalignant condition. Strong consideration should be given to resection in patients with high-grade dysplasia in the setting of Barrett metaplasia. Endoscopic surveillance of patients with Barrett metaplasia may detect adenocarcinoma at an earlier stage more amenable to curative resection. The survival rate of patients with esophageal cancer is poor. Asymptomatic small tumors confined to the esophageal mucosa or submucosa are detected only by chance. Surgery is the treatment of choice for these small tumors. Once symptoms are present (e.g., dysphagia, in most cases), esophageal cancers have usually invaded the muscularis propria or beyond and may have metastasized to lymph nodes or other organs.
In the presence of complete esophageal obstruction without clinical evidence of systemic metastasis, surgical excision of the tumor with mobilization of the stomach to replace the esophagus has been the traditional means of relieving the dysphagia. In the United States, the median age of patients who present with esophageal cancer is 67 years. The results of a retrospective review of 505 consecutive patients who were operated on by a single surgical team over 17 years found no difference in the perioperative mortality, median survival, or palliative benefit of esophagectomy on dysphagia when the group of patients older than 70 years were compared to their younger peers.[Levels of evidence: 3iiA and 3iiB] All of the patients in this series were selected for surgery on the basis of potential operative risk. Age alone should not determine therapy for patients with potentially resectable disease.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the formal ranking system used by the PDQ Editorial Boards to assess evidence supporting the use of specific interventions or approaches. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
The optimal surgical procedure is controversial. One approach advocates transhiatal esophagectomy with anastomosis of the stomach to the cervical esophagus. A second approach advocates abdominal mobilization of the stomach and transthoracic excision of the esophagus with anastomosis of the stomach to the upper thoracic esophagus or the cervical esophagus. One study concluded that transhiatal esophagectomy was associated with lower morbidity than transthoracic esophagectomy with extended en bloc lymphadenectomy; however, median overall disease-free and quality-adjusted survival did not differ significantly. Similarly, no differences in long-term quality of life (QOL) using validated QOL instruments have been reported. In patients with partial esophageal obstruction, dysphagia may, at times, be relieved by placement of an expandable metallic stent  or by radiation therapy if the patient has disseminated disease or is not a candidate for surgery. Alternative methods of relieving dysphagia have been reported, including laser therapy and electrocoagulation to destroy intraluminal tumor.[7,8,9,10]
Surgical treatment of resectable esophageal cancers results in 5-year survival rates of 5% to 30%, with higher survival rates in patients with early-stage cancers. This is associated with a less than 10% operative mortality rate. In an attempt to avoid this perioperative mortality and to relieve dysphagia, definitive radiation therapy in combination with chemotherapy has been studied. A Radiation Therapy Oncology Group randomized trial (RTOG-8501) of chemotherapy and radiation therapy versus radiation therapy alone resulted in an improvement in 5-year survival for the combined modality group (27% vs. 0%).[Level of evidence: 1iiA] An eight-year follow-up of this trial demonstrated an overall survival (OS) rate of 22% for patients receiving chemoradiation therapy. An Eastern Cooperative Oncology Group trial (EST-1282) of 135 patients showed that chemotherapy plus radiation provided a better 2-year survival rate than radiation therapy alone, which was similar to that shown in the Intergroup trial.[Level of evidence: 1iiA] In an attempt to improve upon the results of RTOG-8501, Intergroup-0123 (RTOG-9405) randomly assigned 236 patients with localized esophageal tumors to chemoradiation with high-dose radiation therapy (64.8 Gy) and four monthly cycles of fluorouracil (5-FU) and cisplatin versus conventional-dose radiation therapy (50.4 Gy) and the same chemotherapy schedule. Although originally designed to accrue 298 patients, this trial was closed in 1999 after a planned interim analysis showed that it was statistically unlikely that there would be any advantage to using high-dose radiation. At 2 years' median follow-up, no statistical differences were observed between the high-dose and conventional-dose radiation therapy arms in median survival (13 months vs. 18 months), 2-year survival (31% vs. 40%), or local/regional failures (56% vs. 52%).[Level of evidence: 1iiA]