Esophageal cancer and Barrett's esophagus: How to approach surveillance, treatment, and palliation

Esophageal cancer is an increasingly common problem with poor survival rates in patients who present with symptoms. The underlying cause for the progressive rise in the incidence of this cancer remains to be determined. Reducing mortality requires either early identification of patients or prevention of progression from Barrett's esophagus to cancer. Significant questions remain regarding the cost-effectiveness of endoscopic and nonendoscopic methods of surveillance. For local esophageal cancer, the traditional approach has been surgical resection. Radiation therapy is sometimes used alone, but chemotherapy alone is not helpful. Combination therapy consisting of chemotherapy along with surgery or radiation may be the best choice. A new option being tried in disease limited to the mucosa is ablation of neoplastic tissue with endoscopic techniques. Treatment of advanced-stage esophageal cancer is limited and may be hampered by the presence of micrometastatic disease. Morbidity and quality-of-life issues need to be considered and discussed with patients, given the current short survival time of most patients with esophageal cancer.