Treatment

• Localised disease
• Advanced Oesophageal cancer
• Metastatic and Recurrent disease

Treatment depends entirely on the stage the Oesophageal cancer has reached at the time of diagnosis. The majority of people (60-70%) will have advanced Oesophageal cancer at diagnosis. This is due to the fact that the cancer is too large to remove surgically (called locally advanced disease) or because it has already spread to involve other organs (metastatic disease). These people will not be able to have curative treatment but there are palliative treatment options available for them. They are unlikely to have surgery as part of their treatment although some may have had a ‘staging’ or ‘diagnostic’ laparoscopy which showed disease was too advanced for curative surgery. More detailed staging information is provided for Oesophageal cancers than for other cancers because the Tumor Node Metastasis (TNM) staging system rather than the number grading system will often be used in correspondence about people with Oesophageal cancer.

Localised disease

This can be divided into early and locally advanced cancers and may or may not be treated by curative surgery. Any stage from 0-3 using the number staging system may be suitable for curative treatment, depending on the size and position of the cancer as well as the ability of the person to withstand major surgery. A person’s outcome and survival is related to the treatment they have had rather than the stage of Oesophageal cancer. The table below shows how the stages are described using both systems. Where only TNM staging is given in the correspondence it can be used to give a number stage to the case. Number staging is used throughout malignancies guidance.

Treatment of localised (early stage)

This type of cancer can be removed by surgery and the aim of treatment is to cure the cancer. About 1 in 3 people with oesophageal cancer will be able to have this type of treatment. 5 year survival rates for people who have had curative surgery for oesophageal cancer vary between 20% and 30%. Survival rates for people who have had major surgery for treatment of Barrett’s oesophagus with high grade dysplasia have a much better long term survival than the group as a whole. This is because the oesophagus is removed before cancer develops, sometimes microscopic cancers are found in the oesophagus when it is examined after surgery.

Surgery for oesophageal cancer is major surgery; this means that there is a real risk of dying from complications of surgery in the recovery period (about a 5-10% chance) and that a long recovery time is usually necessary. Oesophageal cancer operations usually involve removing the oesophagus and part of the stomach and making a new oesophagus out of the remaining stomach which is attached to the remaining upper end of the oesophagus in the neck. These operations may or may not involve opening the chest (transthoracic – through the thorax or chest cavity) or operating from below in the abdomen (transhiatal – through the hiatus – the hiatus is the name given to the hole in the diaphragm through which the oesophagus passes). Names of these operations include:

• Transhiatal Oesophagectomy
• Transthoracic Oesophagectomy also called Ivor Lewis procedure/operation
• Oesophagogastrectomy
• Total Oesophagectomy

These are all major operations; partial physical recovery is likely to take about 3 months by which time most people will be coping with self care and be able to take short walks. Fatigue is likely to be a major symptom at this stage. It will usually take anything from 12 months to 2 years for energy levels to return and weight to become stable. Common ongoing problems for someone after this type of surgery include coping with adjusted eating pattern. Most people will need to adjust their diet to eating 6 small meals a day as opposed to 3 and will only be able to tolerate a small volume of food. Also rapid gastric emptying known as “Dumping Syndrome” can have either an immediate or delayed effect on the person after eating and can manifest itself as symptoms of nausea, bloating, pain and diarrhoea.

Chemotherapy and radiotherapy may be used in combination with surgery; if one or both treatments are used they are likely to be given before surgery and to start approximately 12 weeks prior to the operation, e.g. two four day cycles of treatment 3 weeks apart.

Chemotherapy and radiotherapy treatment

Most people who are able to do so will have surgical treatment for their oesophageal cancer as this treatment gives the best chance of long term survival. Sometimes other medical conditions that a person has make oesophageal cancer surgery too risky. For these people combined chemotherapy and radiotherapy (chemoradiation) treatment is an option. Chemotherapy is given over 4 cycles (12 to 16 weeks) and is likely to include the following drugs:

• Fluorouracil
• Cisplatin

Radiotherapy is given during the chemotherapy treatment over 25 to 28 daily sessions (5 to 6 weeks of treatment)

Some people with smaller cancers may be able to have radical radiotherapy treatment alone without having chemotherapy, this treatment involves between 15 and 30 daily doses which takes between 3 and 6 weeks to complete.

Particular problems during treatment in this group are difficulty swallowing and loss of weight and chest discomfort during the treatment. These treatments may increase 5 year survival for this group of patients from 0% to up to around 30%.

Advanced Oesophageal cancer

Advanced oesophageal cancers are rarely curable at all; treatments are usually palliative and aimed at reducing symptoms, improving quality of life and prolonging life expectancy. Most people will die within one year of their diagnosis.

It is likely that someone with advanced oesophageal cancer will have a range of palliative treatments including radiotherapy or chemotherapy to improve symptoms.

Chemotherapy

For advanced oesophageal cancer can reduce symptoms of the disease for a time after diagnosis and improve quality of life. Patients who respond well will also enjoy prolonged life expectancy, but will remain incurable. . A common drug combination is ‘ECF’. This consists of three separate chemotherapy drugs called

• Epirubicin
• Cisplatin
• 5-FU (fluorouracil)

The 5FU is given continuously via a pump into a central line in the neck. The two other drugs are given as injections once every three weeks (a ‘cycle’). More recently, capecitabine (otherwise known as Xeloda) tablets have been used to replace the continuous 5FU infusion (ECX). Patients with squamous cell cancer are likely to have chemotherapy treatment with cisplatin and 5FU every 3 weeks. For the majority of the three weeks a person will be at home and will only go into hospital to have injections of the chemotherapy drugs. 6-8 three week cycles are usually given if there is a good response to the treatment. Total treatment time is 18-24 weeks. Other chemotherapy drugs may be used. Other treatments may be given at the same time as the chemotherapy.

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• Side effects of Chemotherapy

Radiotherapy

This is often given at the same time as chemotherapy treatment – chemoradiation therapy this is because the outcome is better when the treatments are given at the same time. It is usually given to patients with locally advanced disease with curative intent. Radiotherapy is given every day for five weeks with chemotherapy during the first and fifth week. Particular problems during treatment include difficulty swallowing, loss of weight and chest discomfort. Please see general notes for other side effects of chemotherapy and radiotherapy treatment.

Other treatments

These treatments are designed to help reduce the unpleasant symptoms caused by a blocked oesophagus. They are often successful for a time but blockage may re-occur as the tumour grows.

Oesophageal stent

These are self-expanding flexible metal tubes which are placed into the oesophagus passing through the tumour into the stomach they maintain a passageway for swallowing liquids and soft foods but they do not restore the ability to swallow food normally. They can slip or become blocked.

Brachytherapy

This treatment is localised radiotherapy to the tumour in the oesophagus. The treatment is given by placing the radioactive source in the oesophagus for a short period; this is done as a day case procedure. Between one and four separate treatments may be given. Treatment may cause increased soreness and difficulty swallowing for a few days. Swallowing is usually much improved for some weeks or months after treatment.

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• Radiotherapy & Brachytherapy

LASER therapy

This treatment uses an endoscopic LASER to destroy oesophageal cancer cells and can help improve swallowing. Like brachytherapy problems may increase for a few days immediately after the treatment. On average 2 separate sessions will be given as day case procedures.

Photodynamic therapy

This is another form of LASER therapy; a drug is taken up to 4 days before the treatment which makes cells more susceptible to light damage by the LASER light. This treatment is different to ordinary LASER treatment because healthy tissues are less likely to be damaged. However the drug used to make the tumour light sensitive affects skin as well and makes it light sensitive. Preventing skin damage from bright indoor light and ordinary sunlight can be a real challenge. Other side effects and effects of treatment including improved swallowing are about the same as for LASER therapy alone.

Metastatic and Recurrent disease

Many people diagnosed with Oesophageal cancer will be in this group, they are likely to be offered palliative treatment. Staging information in the medical correspondence may use either the TNM or number staging system. This table shows the different way in which advanced disease may be described using the two different systems:

Amended November 2008