Treatment for oesophageal cancer

Very early-stage tumours in the lining of the oesophageal wall (mucosa) may be removed with an endoscope through endoscopic resection (ER). For some people, an endoscopic resection may be the only treatment they need.

This procedure is often done as a day procedure but occasionally needs an overnight stay in hospital. Preparation and recovery are similar to an endoscopy, but there is a slightly higher risk of bleeding or getting a small tear or hole in the oesophagus (perforation).

When oesophageal cancer is inside the oesophageal wall, surgery is often recommended as long as you are well enough.

Surgery aims to remove all of the cancer while keeping as much normal tissue as possible. The surgeon will also remove some healthy tissue around the cancer to reduce the risk of the cancer coming back. You may have an endoscopic resection or an oesophagectomy depending on where the tumour is growing and how advanced the cancer is.

How the surgery is done

To remove the cancer, the surgery can be done in two ways:

• in open surgery, the surgeon will make a large cut in the chest and the abdomen
• in laparoscopic surgery (minimally invasive or keyhole surgery), the surgeon will make some small cuts in the abdomen and/or between the ribs, then insert a thin instrument with a light and camera (laparoscope) into one of the cuts to see inside the body. Sometimes a small cut is made at the base of the neck on the left side. This may be used to join the oesophagus and stomach back together.

Laparoscopic surgery usually means a smaller scar, which means the hospital stay is shorter and the recovery faster, but it’s not always possible to have this type of surgery. Open surgery may be considered a better option in many situations.

Surgery for oesophageal cancer is complex. Surgeons that regularly perform this type of surgery have better outcomes, which means you might need to travel to a specialist centre to have surgery. Call Cancer Council 13 11 20 to ask about patient travel assistance that may be available.

Oesophagectomy (surgical resection)

Surgery to remove part or all of the oesophagus is called oesophagectomy. Nearby affected lymph nodes are also removed. It is common to have chemotherapy and/or radiation therapy before surgery, as this approach has been shown to have better results.

Depending on where in the oesophagus the cancer is, the surgeon may also remove part of the upper stomach. This is the preferred option for cancer that has spread deeper into the wall of the oesophagus or to nearby lymph nodes.

Once the parts with cancer have been removed, the stomach is pulled up and rejoined to the healthy part of the oesophagus. This will allow you to  swallow and, in time, eat relatively normally. If the oesophagus cannot be rejoined to the stomach, the oesophagus will be connected to the small bowel, or a part of the bowel will be used to replace the part of the oesophagus that was removed. These procedures will help you swallow.

Risks of oesophageal surgery

As with any major surgery, oesophageal surgery has risks. These may include infection, bleeding, blood clots, damage to nearby organs, leaking from the joins between the oesophagus and stomach or small bowel, pneumonia and voice changes. Some people may  have an irregular heartbeat, but this usually settles within a few days.

Surgical scars can narrow the oesophagus (known as oesophageal stricture) and make it difficult to swallow. If the oesophagus becomes too narrow, your doctor may need to stretch the walls of the oesophagus (dilatation). For some people, this procedure may need to be repeated several times. Your surgeon will discuss these risks with you before surgery, and you will be carefully monitored for any side effects.

What to expect after oesophageal surgery

Recovery after oesophageal surgery is similar to stomach surgery, but there are some differences.

Recovery time – You will probably be in hospital for 7–10 days, but you may stay longer if you have any complications. It may take 6–12 months to feel completely better after an oesophagectomy.

Drips and drains – You’ll have a feeding tube to get the nutrition you need and another tube (nasogastric tube) to drain fluids from the stomach. The  tubes will be removed before you leave hospital.

Eating and drinking – Immediately after oesophageal surgery, you will not be able to eat or drink. Often a temporary feeding tube is inserted at the time of the surgery. Once you begin eating, it is common to start with fluids such as soup, and then move onto pureed and then soft foods for a few weeks. It is best to eat 5–6 small meals or snacks throughout the day.

Breathing problems – Controlling pain will help avoid problems with breathing that can lead to pneumonia. A physiotherapist can teach you breathing or coughing exercises to help keep your lungs clear. You may also be taught how to use an incentive spirometer, a device you breathe into to help your lungs expand and prevent a chest infection.

Download our booklet ‘Understanding Surgery’

Also known as radiotherapy, this treatment uses a controlled dose of radiation, such as focused x-ray beams, to kill or damage cancer cells. The radiation is targeted at the cancer, and treatment is carefully planned to do as little harm as possible to healthy body tissue near the cancer.

Radiation therapy may be given alone or combined with chemotherapy (see chemoradiation below). Chemoradiation is often used before surgery to shrink large tumours and destroy any cancer cells that may have spread. If you have chemoradiation, you’ll have a break of 4–12 weeks between radiation therapy and surgery to allow the treatment to have its full effect. Radiation therapy, with or without chemotherapy, is used as the main treatment for oesophageal cancer that has not spread to other parts of the body and cannot be removed surgically.

Before starting treatment, you will have a planning appointment that will include a CT scan. The technician may make some small permanent tattoos or temporary marks on your skin so that the same area is targeted during each treatment session.

You will usually have treatment as an outpatient once a day, Monday to Friday, for 4–5 weeks. If radiation therapy is used palliatively, you may have a short course of 1–10 sessions. Each treatment takes about 20 minutes and is not painful. You will lie on a table under a machine that delivers radiation to the affected parts of your body. Your doctor will let you know your treatment schedule.

Chemoradiation for oesophageal cancer

Treatment with radiation therapy and chemotherapy is known as chemoradiation. The chemotherapy drugs make the cancer cells more sensitive to radiation therapy.

Oesophageal cancer may be treated with chemoradiation before surgery to shrink the cancer and make it easier to remove. Chemoradiation may also be used as the main treatment when the tumour can’t be removed safely with surgery, or if the doctor thinks the risk with surgery is too high.

If you have chemoradiation, you will usually have chemotherapy a few hours before some radiation therapy appointments. Your doctor will talk to you about the treatment schedule and how to manage any side effects.

Side effects of radiation therapy

Some people will develop temporary side effects during or shortly after treatment. The lining of the oesophagus can become sore and inflamed  (oesophagitis). This can make swallowing and eating difficult. In rare cases, you may need a temporary feeding tube to help you get enough nutrition. Other possible side effects include fatigue, skin redness, loss of appetite and weight loss. Most side effects improve within four weeks of treatment finishing.

Very rarely, long-term side effects can develop. The oesophagus can develop scar tissue and get narrower (known as oesophageal stricture). Stretching the walls of the oesophagus (dilatation) can make it easier to swallow food and drink. Radiation therapy can also cause irritation and swelling (inflammation) in the lungs, causing shortness of breath.

Download our booklet ‘Understanding Radiation Therapy’

Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells, while causing the least possible damage to healthy cells. Chemotherapy for oesophageal cancer may be given alone or it may be combined with radiation therapy.

For oesophageal cancer, chemotherapy may be used:

• before surgery (neoadjuvant chemotherapy) – to shrink a large tumour and destroy any cancer cells that may have spread
• after surgery (adjuvant chemotherapy) – to reduce the chance of the disease coming back
• on its own (palliative treatment) – for people unable to have surgery or where cancer has spread to different parts of the body.

Chemotherapy is usually given by injecting the drugs into a vein in the arm. It may also be given through a tube that is implanted and stays in your vein throughout treatment (called a port-a-cath or PICC line), or as tablets you swallow. You will usually receive treatment as an outpatient.

Most people have a combination of chemotherapy drugs over several treatment sessions. For each session, the drugs may be given on one day, or continuously over several days using a small pump that is attached to the implanted tube. There may be a rest period of a few weeks between each treatment session.

Side effects of chemotherapy

How you react to chemotherapy will vary, depending on the drugs you receive, how often you have treatment, and your general fitness and health. Some people have few side effects, while others have many. Most side effects are temporary, but some may last longer or be ongoing.

Your treatment team can help you prevent or manage any side effects. Common side effects may include nausea and/or vomiting, sore mouth or mouth ulcers, appetite changes and difficulty swallowing, skin and nail changes, numbness or tingling in the hands or feet, ringing in the ears or hearing loss, changed bowel habits (e.g. constipation, diarrhoea), and hair loss or thinning. You may also be more likely to catch infections. If you feel unwell or have a temperature of 38°C or higher, seek urgent medical attention.

Download our booklet ‘Understanding Chemotherapy’ 

There have been some advances in treating advanced oesophageal cancer with immunotherapy drugs known as checkpoint inhibitors. These use the body’s own immune system to fight cancer.

Clinical trials are testing checkpoint inhibitors for oesophageal cancer after surgery (adjuvant treatment). Checkpoint inhibitors are also given to some people with advanced oesophageal cancer as a first-line treatment together with chemotherapy. New immunotherapy drugs are changing rapidly. Talk to your doctor about whether immunotherapy is an option for you.

Side effects of immunotherapy

The side effects of immunotherapy can vary – not everyone will experience the same effects.

Immunotherapy can cause redness, swelling or pain (inflammation) in any of the organs of the body, leading to common side effects such as fatigue, skin rash and diarrhoea. The inflammation can lead to more serious side effects in some people, but this will be monitored closely and managed quickly.

Download our fact sheet ‘Understanding Immunotherapy’

Palliative treatment helps to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease. It is best thought of as supportive care. Many people think that palliative care is for people at the end of life, but it can help at any stage of advanced oesophageal cancer.

Treatments will be tailored to your individual needs. For example, radiation therapy can help to relieve pain and make swallowing easier by helping to shrink a tumour that is blocking the oesophagus. Palliative treatments can also slow the spread of the cancer.

Palliative treatment is one aspect of palliative care, in which a team of health professionals help meet your physical, emotional, cultural, spiritual and social needs. The team also supports families and carers.

Download our booklet ‘Understanding Palliative Care’

People with advanced oesophageal cancer who are having trouble swallowing and do not have any other treatment options may have a flexible tube (stent) inserted into the oesophagus.

The stent expands the oesophagus to allow fluid and soft food to pass into the stomach more easily. This stent also prevents food and saliva going into the lungs and causing infection. The stent does not treat the cancer but will allow you to eat and drink more normally. Stents can cause indigestion (heartburn) and discomfort. Occasionally, the stents will move down the oesophagus into the stomach and may need to be removed.