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Cervical Esophageal Cancer

Deciding on a Treatment Plan

Your doctors will typically use NCCN Guidelines® for Esophageal and Esophagogastric Junction Cancers to decide on the appropriate treatment course. 5 If these guidelines are not followed, they will discuss it with you and explain why your situation might be special.

Before starting treatment, your doctor will make sure that the following steps are completed.

Pretreatment evaluation

  • A full history and physical examination
  • An evaluation by the members of a head and neck cancer team
  • An upper GI endoscopy and biopsy to confirm a diagnosis of cancer
  • Imaging of the primary tumor, neck, chest, and abdomen
  • Possibly pelvic imaging, as needed
  • PET-CT scan if no evidence of metastatic disease
  • Endoscopic ultrasound if no evidence of metastatic disease
  • Perform lab tests
  • Removal of abnormal lesions found in the digestive tract to confirm an accurate staging of early stage cancer
  • Biopsy of metastatic disease if needed
  • Genetic testing if metastatic adenocarcinoma is suspected
  • Classification of the type of adenocarcinoma tumor (if suspected) to determine extent of surgery
  • Bronchoscopy as needed
  • Nutritional assessment and counseling
  • Smoking cessation advice, counseling as needed
  • Screen family history for genetic risks
  • Pretreatment medical clearance and evaluation of medical conditions

Then your doctor will recommend a course of treatment for you, depending on a number of factors. Like with all cancers in the head and neck, there are three general options to consider:

You should have an extensive discussion with your cancer team to decide upon the best treatment course for you personally. The options that your doctor will recommend will likely be as follows based on the NCCN Guidelines for Esophageal and Esophagogastric Junction Cancers, depending on the stage of cancer you have.5Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Esophageal and Esophagogastric Junction Cancers V.2.2016. ©National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org.

Squamous Cell Carcinoma and Adenocarcinoma

If you are M0 and healthy enough to undergo surgery
  • pTis: Endoscopic therapies, such as endoscopic resection (ER), ablation, ER followed by ablation, are preferred. Another option is surgical removal of the esophagus (esophagectomy)
  • pT1a: ER or ER followed by ablation are preferred, or esophagectomy
  • Superficial pT1b (Only Adenocarcinoma): ER followed by ablation or esophagectomy
  • pT1b, N0: Esophagectomy
  • cT1b, N+ and cT2-T4a, Any N: 
    • Chemotherapy with radiation followed by esophagectomy (or observation if no evidence of disease). For patients with adenocarcinoma, this is the preferred primary treatment. Or,
    • Definitive chemoradiation for patients who decline surgery (recommended for cervical esophagus) or
    • Esophagectomy alone for  non-cervical esophagus tumors (for low risk lesions that are <2cm and well differentiated)
    • If Adenocarcinoma, chemotherapy alone before, during, or after esophagectomy, is also recommended.
  • cT4b: Definitive chemoradiation and esophagectomy only if there is evidence of leftover cancer. If squamous cell carcinoma, your physician may consider chemotherapy alone if the tumor has spread to the trachea, great vessels, or heart.
If you are M0 and not a good candidate for surgery, or 

You choose not to undergo surgery

  • pTis: Endoscopic Resection (ER) or ablation or ER followed by ablation
  • pT1a:  ER or ER followed by ablation
  • pT1b that is not very deep: ER or ER followed by ablation or chemotherapy with radiation for bad tumors
  • cT1b, N+ and cT2-T4a, Any N or cT4b (unresectable): For all other tumors, the options are definitive chemoradiation or palliative radiation or best supportive care.
If you are not a good candidate for surgery, and 

You are not a good candidate for chemotherapy or chemotherapy with radiation therapy 

Your physician will consider radiation therapy to help with symptoms or will offer you a variety of interventions to give you a good quality of life. This is called “best supportive care.”
Stage IV (M1, metastatic disease)  The option here is systemic therapy and/or best supportive care. For esophageal cancer, this might include radiation, chemotherapy, drugs, and surgical procedures to remove obstruction in the esophagus.
References

1 Krause CJ, Carey TE, Ott RW, Hurbis C, McClatchey KD, Regezi JA. Human squamous cell carcinoma. Establishment and characterization of new permanent cell lines. Arch Otolaryngol. Nov 1981;107(11):703-710.

2 Moore C. Smoking and cancer of the mouth, pharynx, and larynx. JAMA: the journal of the American Medical Association. Jan 25 1965;191(4):283-286.

3 Pelucchi C, Gallus S, Garavello W, Bosetti C, La Vecchia C. Cancer risk associated with alcohol and tobacco use: focus on upper aero-digestive tract and liver. Alcohol research & health: the journal of the National Institute on Alcohol Abuse and Alcoholism. 2006;29(3):193-198.

4 Little MP. Cancer after exposure to radiation in the course of treatment for benign and malignant disease. The lancet oncology. Apr 2001;2(4):212-220.

5 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Esophageal and Esophagogastric Junction Cancers V.2.2016. ©National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org.

6 Modlin IM, Shapiro MD, Kidd M. An analysis of rare carcinoid tumors: clarifying these clinical conundrums. World J Surg. 2005 Jan;29(1):92-101.

7 Vinik, A. I., Thompson, N., Eckhauser, F., & Moattari, A. R. (1989). Clinical features of carcinoid syndrome and the use of somatostatin analogue in its management. Acta Oncologica, 28(3), 389-402.

8 Mariette C, Balon J-M, Piessen G, Fabre S, Van Seuningen I, Triboulet J-P. Pattern of recurrence following complete resection of esophageal carcinoma and factors predictive of recurrent disease. Cancer. 2003;97:1616-1623.

9 Key C and Meisner ALW. Chapter 3: Cancer of the Esophagus, Stomach, and Small Intestine. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.