From the Guidelines
Treatment for early-stage oesophageal cancer should prioritize endoscopic resection for T1a oesophageal adenocarcinoma, while oesophagectomy is recommended for T1b oesophageal adenocarcinoma in patients who are fit for surgery and at high risk of cancer progression, as per the latest guidance from the National Institute for Health and Care Excellence (NICE) 1.
Treatment Options for Oesophageal Cancer
Treatment options for oesophageal cancer include:
- Surgery: esophagectomy (removal of part or all of the esophagus) and endoscopic resection for very early-stage cancers
- Chemotherapy: platinum-based drugs (cisplatin or oxaliplatin) combined with fluoropyrimidines (5-fluorouracil or capecitabine)
- Radiation therapy: frequently administered concurrently with chemotherapy (chemoradiation) at doses of 45-50.4 Gy over 5-6 weeks
- Targeted therapy: trastuzumab for HER2-positive adenocarcinomas
- Immunotherapy: checkpoint inhibitors like pembrolizumab or nivolumab for advanced disease
Advanced Oesophageal Cancer Treatment
For advanced oesophageal cancer, first-line treatment with a platinum and fluoropyrimidine is recommended, with the addition of pembrolizumab or nivolumab for patients with PD-L1 expression 1. Key considerations in treatment selection include:
- Cancer stage
- Location
- Histological type (adenocarcinoma vs. squamous cell carcinoma)
- Patient's overall health
- Performance status
Multimodal Approaches
Multimodal approaches combining surgery, chemotherapy, radiation therapy, and targeted therapy often yield the best outcomes, with neoadjuvant (pre-surgery) or adjuvant (post-surgery) therapy improving survival rates in many cases, as supported by studies such as the CROSS trial 1. Supportive care, including nutritional support through feeding tubes if needed, is essential throughout treatment.
From the FDA Drug Label
For the treatment of patients with locally advanced or metastatic esophageal or gastroesophageal junction (GEJ) (tumors with epicenter 1 to 5 centimeters above the GEJ) carcinoma that is not amenable to surgical resection or definitive chemoradiation either: in combination with platinum- and fluoropyrimidine-based chemotherapy, or as a single agent after one or more prior lines of systemic therapy for patients with tumors of squamous cell histology that express PD-L1 (CPS ≥10) as determined by an FDA-approved test.
The treatment options for oesophageal cancer include:
- Combination therapy: pembrolizumab in combination with platinum- and fluoropyrimidine-based chemotherapy for locally advanced or metastatic esophageal or gastroesophageal junction carcinoma.
- Single agent therapy: pembrolizumab as a single agent after one or more prior lines of systemic therapy for patients with tumors of squamous cell histology that express PD-L1 (CPS ≥10). Key considerations:
- PD-L1 expression (CPS ≥10) is required for single agent therapy.
- Patients should not be candidates for surgical resection or definitive chemoradiation. 2
From the Research
Treatment Options for Oesophageal Cancer
- The treatment options for oesophageal cancer depend on the stage and etiology of the disease 3.
- For early-stage oesophageal cancer, endoscopic treatment modalities such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are emerging as frontline treatment options 4, 5.
- Endoscopic ablation procedures, including photodynamic therapy (PDT) and radio frequency ablation (RFA), are also effective and safe for treating esophageal dysplasia and early stage neoplasia 5.
- For locally advanced cancers, a multimodal treatment with neoadjuvant chemotherapy or combined chemoradiotherapy (CRT) followed by surgery is recommended 6.
- Esophagectomy remains the primary treatment for early stage esophageal cancer, although its specific role in superficial cancers is still under debate 6.
Comparison of Endoscopic Resection and Esophagectomy
- Endoscopic resection is associated with fewer major adverse events and lower procedure-related mortality rates compared to esophagectomy 7.
- However, esophagectomy may be associated with better long-term survival outcomes and lower recurrence rates 7.
- The choice between endoscopic resection and esophagectomy depends on the individual patient's condition and the stage of the disease 4, 7.
Advanced Oesophageal Cancer Treatment
- For unresectable esophageal cancer, chemoradiotherapy is the standard treatment 3.
- Neoadjuvant chemoradiotherapy followed by surgery or salvage surgery after definitive chemoradiotherapy is a practical treatment option for advanced oesophageal cancer 3, 6.
- Minimally invasive esophagectomy (MIE) or hybrid operations are being used to reduce perioperative morbidity and mortality without jeopardizing oncological results 6.