Treating Esophageal Cancer by Stage

The type of treatment(s) your doctor recommends will depend on the stage of the cancer and on your overall health. This section sums up the options usually considered for each stage of esophageal cancer.

Treating stage 0 esophagus cancer

A stage 0 tumor contains abnormal cells called high-grade dysplasia and is a type of pre-cancer. The abnormal cells look like cancer cells, but they are only found in the inner layer of cells lining the esophagus (the epithelium). They have not grown into deeper layers of the esophagus. This stage is often diagnosed when someone with Barrett’s esophagus has a routine biopsy.

Options for treatment typically include endoscopic treatments such as photodynamic therapy (PDT), radiofrequency ablation (RFA), or endoscopic mucosal resection (EMR). Long-term follow-up with frequent upper endoscopy is very important after endoscopic treatment to continue to look for pre-cancer (or cancer) cells in the esophagus.

Another option is to have the abnormal part of the esophagus removed with an esophagectomy. This is a major operation, but one advantage of this approach is that it doesn’t require lifelong follow-up with endoscopy.

Treating stage I esophagus cancer

In this stage the cancer has grown into some of the deeper layers of the esophagus wall (past the innermost layer of cells) but has not reached the lymph nodes or other organs.

T1 cancers: Some very early stage I cancers that are only in a small area of the mucosa and haven’t grown into the submucosa (T1a tumors) can be treated with EMR, sometimes followed by another type of endoscopic procedure, like ablation, to destroy any remaining abnormal areas in the esophagus lining. Other times, ablation alone is enough treatment.

But most patients with T1 cancers who are healthy enough will have surgery (esophagectomy) to remove the part of their esophagus that contains the cancer. Chemotherapy and radiation therapy given at the same time (chemoradiation) may be recommended after surgery if there are signs that all of the cancer may not have been removed.

T2 cancers: For patients with cancers that have invaded the muscularis propia (T2 tumors), treatment with chemoradiation is often given before surgery. Surgery alone may be an option for smaller tumors (less than 2 cm). If the cancer is in the part of the esophagus near the stomach, chemo without radiation may be given before surgery.

If the cancer is in the upper part of the esophagus (in the neck), chemoradiation may be recommended as the main treatment instead of surgery. For some patients, this may cure the cancer. Close follow-up with endoscopy is very important in looking for possible signs of cancer returning.

People with stage I cancers who can’t have surgery because they have other serious health problems, or who don’t want surgery, may be treated with EMR and endoscopic ablation, chemo, radiation therapy, or both together (chemoradiation).

Treating stages II and III cancer of the esophagus

Stage II includes cancers that have grown into the main muscle layer of the esophagus or into the connective tissue on the outside of the esophagus. This stage also includes some cancers that have spread to 1 or 2 nearby lymph nodes.

Stage III includes some cancers that have grown through the wall of the esophagus to the outer layer, as well as cancers that have grown into nearby organs or tissues. It also includes most cancers that have spread to nearby lymph nodes.

For people who are healthy enough, treatment for these cancers is most often chemoradiation (chemotherapy plus radiation therapy) followed by surgery. Patients with adenocarcinoma at the place where the stomach and esophagus meet (the gastroesophageal junction) are sometimes treated with chemo (without radiation) followed by surgery. Surgery alone may be an option for some small tumors.

If surgery is the first treatment, chemoradiation may be recommended afterward, especially if the cancer is an adenocarcinoma or if there are signs that some cancer may have been left behind.

In some instances (especially for cancers in the upper part of the esophagus), chemoradiation may be recommended as the main treatment instead of surgery. Patients who do not have surgery need close follow-up with endoscopy to look for possible signs of remaining cancer. Unfortunately, even when cancer cannot be seen, it can still be present below the inner lining of the esophagus, so close follow-up is very important.

People who cannot have surgery because they have other serious health problems or the cancer is too large to remove are usually treated with chemoradiation. If chemoradiation isn’t an option, chemotherapy, immunotherapy, or a combination of the two might be used. Sometimes, two immunotherapy drugs might be used together. For people with gastroesophageal junction cancers that are HER2 positive, immunotherapy with pembrolizumab, plus chemotherapy and the targeted drug trastuzumab might be an option as the first treatment.

Treating stage IV cancer of the esophagus

Stage IV esophageal cancer has spread to distant lymph nodes or to other distant organs.

In general, these cancers are very hard to get rid of completely, so surgery to try to cure the cancer is usually not a good option. Treatment is used mainly to help keep the cancer under control for as long as possible and to relieve any symptoms it is causing.

Chemo may be given (possibly along with targeted drug therapy or immunotherapy) to try to help patients feel better and live longer. Sometimes, two immunotherapy drugs might be used together. Radiation therapy or other treatments may be used to help with pain or trouble swallowing. Another option at some point might be treatment with immunotherapy by itself. If the cancer cells have certain gene changes, a targeted drug such as larotrectinib (Vitrakvi) or entrectinib (Rozlytrek) might be an option.

For cancers that started at the gastroesophageal (GE) junction, treatment with the targeted drug ramucirumab (Cyramza) may be an option at some point. It can be given by itself or combined with chemo. Other options at some point might include treatment with an immunotherapy drug (possibly along with chemo), or the chemotherapy combination pill trifluridine–tipiracil (Lonsurf). If the cancer is HER2-positive, treatment with the targeted drug trastuzumab, plus the immunotherapy drug pembrolizumab, plus chemotherapy, might be an option as the first treatment. The targeted drug fam-trastuzumab deruxtecan (Enhertu) might be an option at some point.

Treating recurrent cancer of the esophagus

Recurrent means the cancer has come back after treatment. The recurrence may be local (near the area of the initial tumor), or it may be in distant organs. Treatment of esophageal cancer that comes back (recurs) after initial treatment depends on where it recurs and what treatments have been used, as well as a person’s health and wishes for further treatment.

Local recurrence

If the cancer was initially treated endoscopically (such as with endoscopic mucosal resection or photodynamic therapy), it most often comes back in the esophagus. This type of recurrence is often treated with surgery to remove the esophagus. If the patient isn’t healthy enough for surgery, the cancer may be treated with chemotherapy, radiation, or both.

If cancer recurs locally (such as in nearby lymph nodes), radiation and/or chemotherapy may be used after the esophagus has been removed. Radiation may not be an option if it was already given as part of the initial treatment. If chemotherapy was given before, it is usually still possible to give more chemotherapy. Sometimes the same drugs that were used before are given again, but often other drugs are used. Other treatment options for local recurrence after surgery might include more surgery or other treatments to help prevent or relieve symptoms.

If the cancer recurs locally after chemoradiation (without surgery), esophagectomy might be an option if the person is healthy enough. If surgery is not possible, treatment options might include chemotherapy or other treatments to help prevent or relieve symptoms.

Distant recurrence

Esophageal cancer that recurs in distant parts of the body is treated like a stage IV cancer.

Your options depend on which, if any, drugs you received before the cancer came back and how long ago you received them, as well as on your health. Radiation therapy may be an option to relieve symptoms as well.

Recurrent cancers can often be hard to treat, so you might also want to ask your doctor if you might be eligible for clinical trials involving newer treatments.

Managing symptoms of recurrent esophageal cancer

Some people prefer not to have treatments that have serious side effects and choose to receive only treatments that will help keep them comfortable and add to their quality of life. For more information on treatments that may be helpful, see Supportive Therapy for Esophageal Cancer.

For more on dealing with cancer recurrence, see Understanding Recurrence.