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:
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.
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