From the Guidelines
Treatment for stage IV esophageal cancer should prioritize a multidisciplinary approach focusing on extending survival and improving quality of life, with systemic chemotherapy, such as FOLFOX or cisplatin with 5-fluorouracil, being a standard treatment regimen, as recommended by the most recent guidelines 1.
Overview of Treatment Options
The treatment of stage IV esophageal cancer involves a comprehensive approach that includes:
- Systemic chemotherapy
- Radiation therapy for symptom management
- Palliative interventions
- Pain management
- Early integration of palliative care
Chemotherapy
Chemotherapy is indicated for palliative treatment in selected patients, particularly those with adenocarcinoma and a good performance status 1. Newer regimens based on oxaliplatin/fluoropyrimidine combinations are an alternative to the classical cisplatin/5-FU schedule.
Radiation Therapy
Radiation therapy is often used for symptom management, particularly for dysphagia relief. Single-dose brachytherapy may be a preferred option, as it provides better long-term relief of dysphagia with fewer complications than metal stent placement 1.
Palliative Interventions
Palliative interventions may include esophageal stent placement to improve swallowing, feeding tube placement for nutrition, or endoscopic procedures to maintain esophageal patency.
Pain Management
Pain management is essential and typically involves opioid medications like morphine or oxycodone, often with adjuvant medications.
Individualized Treatment Decisions
Treatment decisions should be individualized based on the patient's performance status, comorbidities, and personal preferences, with early integration of palliative care to address symptoms and improve quality of life, as emphasized in the latest clinical practice guideline 1.
Key Considerations
- The goal is to balance treatment effectiveness with side effect management to maintain the best possible quality of life.
- The treatment paradigms for oesophageal SCC versus oesophageal AC have taken divergent paths due to the results of randomised phase III trials in the two histological subtypes, and the differing response of SCC and AC to CRT 1.
From the FDA Drug Label
The safety and efficacy of trastuzumab in combination with cisplatin and a fluoropyrimidine (capecitabine or 5-fluorouracil) were studied in patients previously untreated for metastatic gastric or gastroesophageal junction adenocarcinoma (ToGA)
On the trastuzumab-containing arm, trastuzumab was administered as an IV infusion at an initial dose of 8 mg/kg followed by 6 mg/kg every 3 weeks until disease progression.
The treatment options for Stage IV Esophageal Cancer may include trastuzumab in combination with cisplatin and a fluoropyrimidine (such as capecitabine or 5-fluorouracil), for patients with HER2-positive metastatic gastric or gastroesophageal junction adenocarcinoma 2.
- Key points:
- Trastuzumab is administered as an IV infusion at an initial dose of 8 mg/kg followed by 6 mg/kg every 3 weeks until disease progression.
- Cisplatin is administered at a dose of 80 mg/m2 Day 1 every 3 weeks for 6 cycles.
- Capecitabine or 5-fluorouracil is administered as part of the chemotherapy regimen.
From the Research
Treatment Options for Stage IV Esophageal Cancer
- The treatment options for Stage IV esophageal cancer include targeted therapy and immunotherapy, as well as chemotherapy and radiotherapy 3, 4, 5.
- Targeted therapy with anti-human epidermal growth factor receptor 2 (HER2) agents, such as trastuzumab, has been approved for use in patients with HER2 positive gastro-esophageal adenocarcinoma 3.
- Immunotherapy with immune checkpoint inhibitors, such as nivolumab and pembrolizumab, has also been approved for use in esophageal cancer patients for specific indications 3, 4, 5.
- Chemotherapy and radiotherapy are also used to treat Stage IV esophageal cancer, with options including concurrent chemoradiotherapy with intermittent standard-dose cisplatin and 5-fluorouracil (ISD-FP) or daily low-dose cisplatin with continuous infusion of 5-FU (CLD-FP) 6.
- The combination of an immune checkpoint inhibitor and chemotherapy has been shown to be effective and safe for the initial treatment of advanced esophageal cancer 4.
- After first-line treatment, taxane or irinotecan may be used, and immune checkpoint inhibitors such as pembrolizumab and nivolumab may be used as second-line treatments 5.
Safety and Efficacy of Treatment Options
- The safety profiles of cytotoxic agents and immune checkpoint inhibitors differ, with immune checkpoint inhibitors having a lower risk of certain toxicities but a higher risk of immune-related adverse events 5.
- Regular monitoring of physical and laboratory examinations is needed during and after the administration of immune checkpoint inhibitors to manage potential toxicities 5.
- The efficacy of treatment options for Stage IV esophageal cancer varies, with some studies showing improved overall survival rates with certain combinations of therapies 3, 4, 5.