Gastroesophageal Cancer

Gastroesophageal Cancer Treatment

Gastroesophageal cancer (GEC), comprising proximal esophagogastric junction (EGJ) and distal gastric cancer (GC), is a significant public health concern. The epidemiology of these tumors has significantly changed over the past several decades especially in developed countries. There is a recognized decrease in incidence and mortality of distal GC and an increase in incidence and mortality of proximal EGJ cancer. The changing epidemiology is thought to be mainly due to changing trends of risk factors such as lower incidence of Helicobacter pylori infection and increasing incidence of obesity and gastroesophageal reflux. Histologically, EGJ cancers are adenocarcinoma (AC), while distal esophagus may be squamous cell carcinoma (SCC) or AC. Distal GC is predominantly AC. Following anatomical and histological distinction, tumors are staged with endoscopic ultrasound (EUS), computerized tomography (CT), and often positron emission tomography (PET) with or without diagnostic laparoscopic and peritoneal washing. Accurate staging of tumors, with emphasis on excluding occult metastasis, is imperative to avoid unnecessary surgical resection.

Treating Stage by stage

Stage 0

A stage 0 tumor is not true cancer. It contains abnormal cells called high-grade dysplasia and is really 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 Barretts 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.

Stage I

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 havent grown into the submucosa (T1a tumors) can be treated with EMR, usually followed by some type of endoscopic procedure to destroy any remaining abnormal areas in the esophagus lining.

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. The targeted drug trastuzumab (Herceptin) may be given with chemo if the cancer is HER2 positive and no radiation is given.

People with stage I cancers who cant have surgery because they have other serious health problems, or who dont want surgery, may be treated with EMR and endoscopic ablation, chemo, radiation therapy, or both together (chemoradiation).

Stages II and III

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 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. The targeted drug trastuzumab may be given with chemo if the cancer is HER2 positive and no radiation is given. 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.

Patients who cannot have surgery because they have other serious health problems are usually treated with chemoradiation.

Stage IV

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 the targeted drug trastuzumab if the cancer is HER2 positive) to try to help patients feel better and live longer, but the benefit of giving chemo is not clear. Radiation therapy or other treatments may be used to help with pain or trouble swallowing.
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.