Oesophageal Cancer Treatment

If a person’s cancer is confined the inner ‘mucosal’ lining, then less invasive endoscopic treatments are usually recommended. Endoscopies involve passing thin flexible tubes down the throat of a sedated patient to deliver the treatment, so no cuts to the abdomen to reach to the oesophagus. Sometimes several sessions are needed, but recovery is straight forward most patients are discharged same day or within 24 hours.

• Endoscopic Mucosal Resection (EMR): Removes superficial tumours from the mucosa (inner lining) using an endoscope
• Endoscopic Submucosal Dissection (ESD): A more advanced method used for larger tumours that are still confined to the inner layers of the food pipe

Stage 1 Oesophageal cancers are confined to the food pipe, but may involve deeper layers (beyond the inner lining or mucosa). Some small cancers may only need an Endoscopic Submucosal Dissection (ESD) (see above), but usually they require surgical treatment.

• Oesophagectomy: is the main surgical treatment for Stage I tumours that are not suitable for endoscopic resection. It involves removing part or all of the oesophagus and reconstructing the digestive tract using the stomach or intestine. This surgery may be done through a minimally invasive (laparoscopic or robotic) approach, or open surgery, depending on tumour location and other factors
  • There are two common surgical approaches Transhiatal Oesophagectomy (where the oesophagus is removed through the neck and abdomen) and Transthoracic Oesophagectomy (where the oesophagus is removed via the chest and abdomen)
  • After the oesophagus is removed the digestive tract may be reconstructed using the stomach or a piece of intestine (surgical reconstruction) so that function is retained
• ‘Neoadjuvant Chemotherapy’ is commonly the first treatment. The purpose of neoadjuvant chemotherapy is to shrink the tumour first, making it easier to remove or treat with surgery. The specific chemotherapy regimen (e.g. FLOT or FOLFOX) may vary based on the patient’s overall health, the type of oesophageal cancer (adenocarcinoma or squamous cell carcinoma), and other individual factors. There is more about chemotherapy regimes in the next section. Chemotherapy (FLOT) is usually given for 8 weeks before and after surgery and this produces the very best outcomes for patients, although it is a tough chemotherapy. 

Sometimes radiotherapy treatment is given before surgery to reduce the size of the tumour (neoadjuvant chemoradiotherapy).

An Oesophageal Cancer in stage II or III is caused ‘locally advanced’. This means that Cancer has spread beyond the food pipe, but not very far. A stage II patient will have Oesophageal Cancer that has spread to nearby lymph nodes or surrounding tissues but is still limited to the oesophagus and nearby structures. A stage III patient will have Oesophageal cancer that has spread further into nearby tissues, organs, or lymph nodes.

Surgery on its own is rare for a patient with Stage II-III oesophageal cancer. Usually, the person will have chemotherapy pre and post operative (before and after surgery). 

Sometimes, treatment starts with Neoadjuvant Chemoradiotherapy, this means combining chemotherapy and radiotherapy together. Treatment plans are completely individualised which is why it sounds very complicated. Surgery alone is rare. Most commonly chemotherapy (FLOT) is given before and after surgery. Chemoradiotherapy is sometimes used before surgery or as a definitive treatment in its own right if surgery is not possible for a variety of reasons.

Chemotherapy – this involves the use of drugs to destroy cancer cells throughout the body. These are some common chemotherapy drugs which are often used in a ‘regimen’ (e.g. combination) and alongside with radiotherapy or surgery.

• Cisplatin: A platinum-based chemotherapy drug that damages cancer cell DNA.
• Carboplatin: A less toxic alternative to cisplatin, sometimes used for advanced cases.
• 5-FU (Fluorouracil): A chemotherapy drug that interferes with cancer cell growth.
• Oxaliplatin -platinum-based chemotherapy agent, which work by interfering with the DNA in cancer cells, preventing them from growing and dividing
• Docetaxel: A chemotherapy drug that prevents cancer cells from dividing.

There are two main regimens for people with Oesophageal Cancer. Cisplatin + 5-FU used to be the most common, but FLOT is a newer treatment combination and is now standard of care. The name FLOT comes from the initials of the drugs used in the treatment (F: Fluorouracil (5FU), L: Leucovorin (also called calcium folinate or folinic acid), O: Oxaliplatin and T: DoceTaxel). L: Leucovorin (also called calcium folinate or folinic acid) is a medication used to reduce the toxic effects of certain chemotherapy drugs

• Radiotherapy is the other part of Chemoradiotherapy (the standard treatment for locally advanced oesophageal cancer). Radiation therapy is used to destroy cancer cells by targeting the tumour with high-energy rays. Chemotherapy drugs are combined with radiation therapy to target and destroy cancer cells

Key Clinical Trials Supporting Chemoradiotherapy

These trials collectively support the use of chemoradiotherapy as an effective treatment for locally advanced oesophageal cancer, offering improved survival outcomes compared to surgery alone.

• CROSS Trial: This pivotal study compared neoadjuvant chemoradiotherapy (cisplatin, 5-fluorouracil, and radiation) followed by surgery to surgery alone in patients with locally advanced oesophageal cancer. Results showed that the chemoradiotherapy group had significantly improved overall survival and progression-free survival rates.
  JAMA Network
• NEOCRTEC5010 Trial: This phase III multi-centre trial evaluated neoadjuvant chemoradiotherapy followed by surgery versus surgery alone in patients with locally advanced oesophageal squamous cell carcinoma. The study found that the combination therapy led to higher rates of pathological complete response and improved survival outcomes.  JAMA Network
• FLOT4 Trial: This trial looked at the combination of FLOT chemotherapy (Docetaxel + Oxaliplatin + Fluorouracil + Leucovorin) for patients with advanced oesophageal cancer.  The FLOT regimen showed improved survival rates for patients with locally advanced oesophageal cancer compared to traditional chemotherapy regimens.

Chemoradiotherapy as the primary treatment for Oesophageal Cancer

Chemoradiotherapy combines chemotherapy and radiation therapy to treat oesophageal cancer. It can be used for patients who cannot undergo surgery (due to the location of the tumour or their health) it may be used instead of Surgery (known as Definitive Chemoradiotherapy).

Advanced Oesophageal Cancer, sometimes referred to as Metastatic or Stage IV, means the cancer has spread to other parts of the body, such as the liver, lungs or another organ in even a distant part of the body. These patients will likely be offered treatments such as chemotherapy, targeted therapy and/or immunotherapy. 

• Chemotherapy is the standard treatment for Stage IV oesophageal cancer. It helps shrink or slow the growth of the cancer and relieve symptoms. Different chemotherapy drugs can be used in combination to make them more powerful at tackling Oesophageal Cancer. 
• Common chemotherapy regimens include Cisplatin + 5-FU or Cisplatin + Docetaxel or FOLFOX (see above). The regimen depends on the type of cancer a patient has, but the drugs work in similar ways by damaging or destroying cancer cells