Esophageal cancer

Esophageal cancer is a major health hazard in many parts of the world. Several advances have been made in staging procedures and therapeutic approaches. Unfortunately, esophageal cancer is often diagnosed late; therefore, most therapeutic approaches are palliative. Multidisciplinary team management is essential for treating patients with esophageat cancer. SCC and adenocarcinoma are the 2 major types of esophageat cancer. SCC is most common in endemic regions, whereas adenocarcinoma is most common in nonendemic regions. Smoking and alcohol abuse are major risk factors for SCC. Barrett's esophagus, obesity, and GERD seem to be major risk factors for development of adenocarcinoma of the esophagus or GE junction. Esophagectomy is considered the preferred primary treatment option for patients with resectable T1b, N0, or NX tumors. In medically fit patients with more advanced cancers, such as T1b, N1 to T4, N0-1, NX, or stage IVA, primary treatment options include definitive chemoradiation, preoperative chemotherapy, or chemoradiation followed by esophagectomy. Medically unfit patients may be offered definitive chemoradiation. Postoperative treatment is based on histology, surgical margins, and nodal status. In patients with SCC who have no residual disease at surgical margins (R0 resection), no further treatment is recommended, irrespective of their nodal status. Fluoropyrimidine-based chemoradiation is recommended for patients with node-positive and -negative adenocarcinoma who have T2, N0 tumors with high-risk features and T3, N0 tumors. Postoperative chemotherapy may be considered (only if they underwent preoperative chemotherapy) for patients with resectable adenocarcinoma of the lower esophagus and GE junction. All patients with residual disease at surgical margins (R1 and R2 resections) may be treated with fluoropyrimidine-based chemoradiation. Concurrent chemoradiation with a fluoropyrimidine-based regimen is recommended for unresectable disease in patients medically unfit for surgery and able to tolerate chemotherapy. Best supportive care is an integral part of treatment, especially in patients with locally advanced disease. Assessing disease severity and related symptoms is essential to initiate appropriate palliative interventions that will prevent and relieve suffering and improve quality of life for patients and their caregivers. Metastatic disease in patients with good performance status can be treated with chemotherapy plus best supportive care, whereas best supportive care is recommended for those with poor performance status. Endoscopic palliation of esophageal cancer has improved substantially because of improving technology. The NCCN Clinical Practice Guidelines in Oncology: Esophageal Cancer (in this issue; to view the most recent version, visit www.nccn.org) emphasize that considerable advances have been made in the treatment of locoregional esophageal cancer. Novel therapeutic modalities, such as targeted therapies, vaccines, gene therapy, and antiangiogenic agents, are being studied in clinical trials for patients with esophageal cancer. The panel encourages patients with esophageal cancer to participate in well-designed clinical trials to enable further advances.