Treatment

Removing the cancerous tissue in your esophagus (and possibly in nearby structures) is important to treating your disease.

If you have small, early-stage cancer that has not gone deeper than the lining (mucosa) of your esophagus, doctors may be able to remove all of it using an outpatient method called endoscopic mucosal resection (EMR). Therapeutic gastroenterologists in Digestive Health at UW Medical Center do this procedure.

• You are sedated (given medicine to make you sleepy and relaxed). 
• The doctor inserts a thin, flexible tube (endoscope) into your mouth or nose and down into your esophagus. 
• The endoscope has a light and a tiny camera on the end to take close-up images, which show on a video monitor in the exam room.
• The doctor uses instruments to remove (resect) a small amount of tissue.
• A pathologist checks the tissue under a microscope to determine if cancer is present and what type of cancer it is.  

EMR can be used both to diagnose cancer and, if all the cancer is removed this way, to treat cancer. It is less invasive than surgery and allows patients to resume their life immediately with better outcomes.

Your Fred Hutch team may recommend surgery to remove part or all of your esophagus (esophagectomy) if:

• You have early-stage cancer that cannot be removed with EMR.
• You have locally advanced cancer (which may have spread through layers of your esophagus and to nearby structures, such as lymph nodes).

People with metastatic esophageal cancer (which has spread to distant parts of the body) have other treatment options. They typically do not have surgery because surgery cannot remove the cancer completely. 

Fred Hutch patients receive esophageal cancer surgery from top surgeons at UW Medicine's Thoracic Surgery Clinic and Center for Esophageal & Gastric Surgery, among only a few sites in the country that specialize in diagnosing and surgically treating thoracic and esophageal cancers. Here, the same experts take care of people with cancer in their stomach, esophagus or the place where these structures meet (gastroesophageal junction). Studies show that performing a high volume of esophagectomies, as our surgeons do, is a strong predictor of better patient outcomes, including lower risk of major complications. 

There are many ways to perform an esophagectomy.

• The method your surgeon uses will depend on the location of your tumor.
• UW Medicine surgeons are on the leading edge of developing new techniques and teaching these techniques to other doctors.
• Whichever procedure you have, your Fred Hutch team will work with you to ensure you receive the care you need before, during and after, as you recover.

Transhiatal esophagectomy Your surgeon removes most of your esophagus through incisions in your neck and abdomen. Typically they attach your stomach to your remaining esophagus in your neck. Sometimes, a segment of the colon is used to connect the esophagus to the stomach. There’s no incision in your chest, and your lungs do not have to be deflated to reach your esophagus, so this method may reduce complications like pneumonia.
Ivor-Lewis esophagectomy Your surgeon removes the lower half of your esophagus through an incision in your abdomen. They attach your stomach to your upper esophagus through an incision in your chest along your ribs.
Total esophagectomy For large tumors in the middle of your esophagus, your surgeon removes the entire esophagus. They separate your esophagus from other chest structures and organs through incisions in your neck, chest and abdomen, and they create a new passage for food from your throat to your stomach, typically with a segment of your intestine.
Minimally invasive surgery Most SCCA patients who need surgery for esophageal cancer can have minimally invasive surgery, done with a fiber-optic camera and small instruments through incisions only one-quarter to one-half inch long. The benefits include less pain, faster recovery and fewer problems than with longer incisions. Our surgeons are among the country’s leading experts in minimally invasive surgery in the chest (thoracoscopy) and abdomen (laparoscopy).

Chemotherapy may be part of your treatment:

• Before surgery to shrink your tumor
• After surgery to destroy any remaining cancer cells 
• As your main treatment to help control cancer if you don’t have surgery

Usually chemotherapy medicines are given by infusion into a vein. Then they enter your bloodstream and travel throughout your body. Some are given in pill form.

You may have chemo alone or in combination with radiation therapy (chemoradiation) because chemotherapy medicines can make cancer cells more sensitive to radiation. 

Your Fred Hutch team will talk with you about the specific medicines we recommend for you, how you’ll receive them, your treatment schedule and what to expect. We’ll also explain how to take the best possible care of yourself during treatment and after, and we’ll connect you with medical and support resources throughout Fred Hutch.

Targeted therapies are newer cancer treatments that work more selectively than standard chemotherapy.  They target a gene or protein responsible for allowing cancer to grow, they seek out and damage cancer cells, or they prompt your immune system to attack particular cells (also called immunotherapy).

Trastuzumab (Herceptin) is a type of targeted therapy called monoclonal antibody therapy. It uses antibodies to identify substances on cancer cells that may help cancer cells grow. The antibodies attach to these substances and kill the cancer cells, block their growth or keep them from spreading.

Trastuzumab preferentially attacks cancer cells that make too much of the HER2/neu protein. If you have adenocarcinoma that tests positive for HER2/neu, you would be a candidate for trastuzumab.

Immunotherapies harness your body’s immune system to fight your cancer. One type is called an immune checkpoint inhibitor. These medicines block proteins that normally keep your immune cells in check so that they do not become overactive.

An immune checkpoint inhibitor used for esophageal cancer is pembrolizumab (Keytruda). It blocks the protein PD-1, taking the brakes off your T cells and allowing these immune cells to attack your cancer.

You may have radiation therapy:

• Before surgery to shrink your tumor
• After surgery to destroy any remaining cancer cells
• To control your disease if you’re not a candidate for surgery
• To help with the effects of your cancer, such as a blocked esophagus

Radiation therapy uses high-energy rays or other types of radiation to kill cancer cells. Two main types are used for esophageal cancer: 

• External-beam radiation therapy (EBRT) using X-rays 
• Proton therapy, a unique form of EBRT that targets protons at tumors

X-ray EBRT

EBRT uses a machine called a linear accelerator to deliver invisible beams of radiation to your cancer. At our state-of-the-art radiation centers, we use four-dimensional scans to plan your care and account for the movement of your tumor as you breath. Using image guidance, we aim the beams precisely at your tumor at each treatment. 

Combining chemotherapy and radiation (chemoradiation) is common for esophageal cancer because chemotherapy medicines can make cancer cells more sensitive to radiation. Our highly trained specialists have extensive experience caring for people who are going through this aggressive form of treatment. 

Proton therapy

Proton therapy is an advanced therapy and an important alternative to conventional radiation for many types of cancer (and some noncancerous tumors).
 
Proton therapy is sometimes recommended for esophageal cancer because it may significantly limit radiation exposure to surrounding healthy tissue near your esophagus, such as your heart and lungs. The advantage of using protons to treat this cancer is that doctors can target high doses of radiation at the cancer with the goal of minimizing radiation to healthy tissues. This may reduce side effects.
 
Fred Hutchinson Cancer Center - Proton Therapy is the only facility in a seven-state region to offer this treatment. Learn more about proton therapy for gastrointestinal cancers.

During and after your treatment for esophageal cancer, it’s important to maintain good nutrition so you’re as strong and healthy as you can be. At times, this may be challenging because both the disease and its treatments might affect your desire and ability to eat and drink.

The best time to get nutritional advice is before you develop any nutritional problems. With the right guidance, you may be able to prevent problems before they start. But no matter where you are in your treatment, your Fred Hutch team is ready to help.

Dietitians are available to work with you to:

• Prepare your body for treatment by eating well before treatment starts.
• Set specific goals for adequate nutrition and fluid intake, and check whether you’re getting enough.
• Figure out which foods are easiest to tolerate with your symptoms.
• Find ways to maintain or increase protein intake to help keep up muscle mass and weight.
• Choose nutrient-dense foods to get as much nutrition as possible with every meal.
• Change your diet after surgery, such as eating smaller portions of soft foods, avoiding high-fat and spicy dishes and not drinking liquids with meals.

Learn More About Fred Hutch Nutrition Services