Annie76~In my opinion-pre-op chemo/radiation is like "2 for the price of 1"~tri-modal treatment most

LorettaMarshall

My dear Annie:

First let me say that I am putting my answer on a completely new topic forum for one reason.  It is so lengthy and detailed that if someone else wants to comment on your original post, they will have difficulty “finding the bottom of all this information.”  And further, it will serve as a primer for other Esophageal Cancer newbies that need to know basic truths about Esophageal Cancer.”  Many of the terms will be “new” to you for the first time, but you will learn to recognize them because it will be “normal speak” for the doctors who will be treating your husband.

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So this is your original post:  https://csn.cancer.org/node/311731

“Change in Treatment - Sep 01, 2017 - 3:21 pm

My husband was recently diagnosed with gastro-esophageal cancer.  He was to begin a combination of chemo-radiation next week.  After his radiation simulation and Pet Scan the radiologist determined that the lymph nodes were too large to begin radiation at this time. He will start with chemotherapy only at this time.  This is concerning to us.  Has anyone else experienced this change to their treatment?  What should we expect?  Annie76”

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 That said, let me say welcome to “our Esophageal Cancer family”. You ask, “What should you expect?”  My simple answer would be, “You should expect a real good medical reason as to why these doctors say the size of the lymph nodes is a “disqualifier” for radiation!  And then, you should have a SECOND opinion.  If you have an HMO, it may require you seeking out another medical team in your NETWORK and first getting a referral.  That’s a hurdle HMO often requires!   But if you have a PPO such as ETNA, ANTHEM, etc. usually you won’t need a special referral.  At least that is what many of my EC friends have told me, so I’m always happy to learn that they don’t have to jump through hoops to go to a good hospital where one of their specialties is the treatment of Esophageal Cancer. 

Some here are actively in treatment, while others are long-term survivors having successfully completed their chemo/radiation and surgical experience.  Had you given us more of an introduction into the history of how and where your husband was diagnosed with Esophageal Cancer, we would be at a better advantage as to how to help.  That said, speaking for myself, I am only familiar with chemotherapy and radiation combinations for the treatment of Esophageal Cancer.  In my time here, I haven’t “heard that cancerous nodal size is reason to forego radiation and only pursue chemotherapy.”

To begin with, have you had a SECOND opinion at a major medical facility that is noted for treating Esophageal Cancer successfully?  Larger hospitals are much more experienced at dealing with Esophageal Cancer.  The surgery is MAJOR.  Most often after thorough exams and staging, a neoadjuvant (pre-op) series of chemotherapy and radiation is prescribed.  This can be done at a medical facility near your home under the supervision of a highly-recommended oncologist.  It is not uncommon for patients, after having their diagnosis CONFIRMED, to undergo chemo/radiation treatments locally, and then travel to a major medical facility which has “high ranks” in dealing with Esophageal Cancer.

1.      So, first of all, what is the exact stage of your husband’s cancer?

2.      Is it “Adenocarcinoma” or “Squamous Cell” Esophageal cancer? 

3.      What tests were given to determine this finding?

4.      Was your husband tested for HER2 positive?  (Human Epidermal Growth Factor Receptor 2, a condition in which an oncogene is over-expressive and causes the cancer to spread much more rapidly.) 

5.      If he was tested, and it was found to be positive , was HERCEPTIN mentioned?

6.      How many lymph nodeswere found to contain cancer?

7.      Was a biopsy performed?

8.      Have the doctors said that your husband is a surgical candidate?  That all depends on the STAGE of Esophageal cancer you know.  Not everyone qualifies for surgery, so sad to say.

9.      How long did your husband have symptoms, and what were they, prior to seeking medical advice?

10.  What kind of chemo are these doctors saying they wish to use, and for how long?

I’m not a medical person, but have spent long hours reading about facts surrounding Esophageal Cancer, since my husband was diagnosed in November of 2002 with Esophageal Cancer (Adenocarcinoma at the Gastroesophageal (GE) Junction) (EC T3N1M0).  This meant that ALL 4 walls of his Esophagus were infiltrated with cancer, as well as 2 local lymph nodes.  His medical team prescribed neoadjuvant (pre-op) chemo/radiation treatments prior to having an Ivor Lewis MINIMALLY INVASIVE ESOPHAGECTOMY.  The pre-op chemo/radiation therapy was totally successful in eradicating the cancer, and then surgery was performed on May 17, 2003 at the University of Pittsburgh Medical Center by Dr. James D. Luketich.  Dr. Luketich pioneered this laparoscopic procedure in the mid-90s.  Now it is being utilized greatly because it has proven to be the least invasive with the shortest period of recovery, less complications, less blood loss, shorter hospital stays, etc.  So that’s our story.

Now let me say, that I do not understand why radiation is not recommended.  Personally, I’ve never read about lymph nodes not being treated because they were TOO LARGE!  If I were you, I would not be satisfied without a clearer explanation, or at least you haven’t given us one.  Just how large are the nodes, not that that clarifies anything for me.  A CT Scan gives measurements in centimeters, as well as sizes and shapes.   

So my best advice for you would be, “run—don’t walk” to a major medical facility as soon as possible and have a SECOND OPINION.  If you care to tell us more about the vicinity in which you reside, we might be able to recommend a hospital that is known for excellent care and treatment of Esophageal Cancer patients.

Did you know that a recent article released in April of this year by Mayo Clinic in Rochester, MN, stated that only 12% of first opinions were correct?  The remainder were altered in some form, or were “downright WRONG!”

It just may be that another facility will recommend a totally different treatment that includes both chemo and radiation.  I will say that in all my research, chemo/radiation given most often prior to surgery, is the norm.  Clinical trials have proven that EC patients who receive the “tri-modal” treatment have the best success rates.  Chemo circulates throughout the entire body as the article from “ONCOLINK” below states.  Radiation targets the tumor itself.  Sometimes it serves to “reduce it altogether” or reduce its size.  In all that I’ve read, the chemo/radiation treatment is standard practice for patients that have been diagnosed with Esophageal cancer, and their stage is such that they qualify as surgical candidates.

Not knowing how familiar you are with Esophageal Cancer, I’m guessing that you are like most of us, and are entering into a “whole new world” where you never wanted to be!  At least that’s where most of us that are writing here were in the beginning.  So for your information, I’ve listed some references below.  I suggest you read ALL the reference, although I have highlighted and put in bold print some of the info you should take note of.  The different STAGES of EC are listed.

So don’t be afraid to ask questions and do expect answers that you can understand.  You know when we were kids, and would question our parents on WHY we had to do so and so, the resounding answer would be, “BECAUSE I SAID SO!”  But we’re grownups now, and we should be asking questions and deserving answers.  I want a good relationship with my medical team.  I want to be able to ask questions.  I’m not one to just sit back, ask no questions, and say “duh…”  It’s MY LIFE!  If your doctor is too busy to provide explanations, that’s certainly a reason to go elsewhere.  And especially if he/she appears to be “offended” at your decision to verify their findings by consulting another separate medical team, that is doubly a reason to “move on.” 

That said, someone else here may be able to tell you more, but for the time being, I’ve said all I know to say.  Please stay in touch as there may be questions that we can answer along the way.

Naturally, we wish for you and your husband total success.  Where you choose to seek treatment, and what type will make all the difference.  We totally understand your emotional state since so many of us have “been there—done that!” We know the uncertainties and trials that patients and their caregivers experience.  So just make yourself “at home here.” 

Sincere best wishes,

Loretta - (Wife of William, EC T3N1M0, DX November 2002, Ivor Lewis Minimally Invasive Esophagectomy performed by Dr. James D. Luketich @ University of Pittsburgh Medical Center, May 17, 2003.  Checkup yesterday, August 31, 2017 revealed still "NED" - No evidence of disease.  We call it a gift from God.)

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1.       http://www.gomn.com/news/mayo-clinic-says-get-a-second-opinion-first-ones-are-frequently-wrong/

“Mayo Clinic says get a second opinion – first ones are frequently wrong

By Melissa Turtinen - April 4, 2017 12:17 pm

If you’re diagnosed with an illness, you might want to get a second opinion.

The Mayo Clinic in Rochester did a study (published in a medical journal Tuesday) and found as many as 88 percent of patients who came to the clinic for a second opinion for a complex condition left with a new or more refined diagnosis, a news release says.

The Mayo Clinic says a different or more detailed diagnosis can change someone’s care plan “and potentially their lives.”

The study looked at 286 patients who were referred from primary care providers to Mayo Clinic’s General Internal Medicine Division in Rochester between Jan. 1, 2009, and Dec. 31, 2010. Here’s how the types of diagnostic errors breaks down:

• Only 12 percent of patients left the Mayo Clinic with the same diagnosis.
• In 21 percent of cases, the diagnosis was changed completely.
• In 66 percent of patients, their diagnosis was refined or redefined…”
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2.      https://www.cancer.gov/types/esophageal/patient/esophageal-treatment-pdq

“…Esophageal cancer is a disease in which malignant (cancer) cells form in the tissues of the esophagus.

The esophagus is the hollow, muscular tube that moves food and liquid from the throat to the stomach. The wall of the esophagus is made up of several layers of tissue, including mucous membrane, muscle, and connective tissue. Esophageal cancer starts on the inside lining of the esophagus and spreads outward through the other layers as it grows…”

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3.      http://news.cancerconnect.com/types-of-cancer/esophageal-cancer/esophageal-cancer-overview/

 [My note Annie:  Please read entire article, I’ve only quoted part of it here.  That goes for all the reference links.]

“…Staging of Esophageal Cancer

If possible, it is important to determine the extent of cancer before treatment in order to select the best treatment option. Of particular concern is the presence of cancer in lymph nodes, spread of cancer to distant sites or local extension of cancer into surrounding structures, which might make attempts to remove all cancer with surgical resection impossible. Unfortunately, in many cases the true extent of spread of cancer can only be determined by surgical resection. Frequently, more advanced cancer is found at surgery than was detected by clinical tests.

Routine Staging: All patients with esophageal cancer undergo a routine chest x-ray examination and a barium swallow under fluoroscopy (direct x-ray examination of the esophagus) as part of initial staging evaluation. All patients have computerized tomography (CT) scans of the chest, upper abdomen and possibly the neck. Unfortunately, there can be considerable error in CT scanning in detecting the extent of local spread of esophageal cancer, but accuracy for detecting distant spread (metastasis) is good.

Esophagoscopy: An esophagoscopy is an examination performed through an endoscope, which is a flexible tube inserted through the esophagus that allows the physician to visualize, photograph and biopsy (sample) the cancer. All patients undergo an esophagoscopy with biopsy to determine the histology or appearance of the cancer under the microscope.

Thoracoscopy: A thoracoscopy is another procedure performed through an endoscope to examine the chest in order to determine the extent of spread of cancer in the chest.

Laparoscopy: Laparoscopy is a procedure that involves the insertion of an endoscope through a small incision in the abdomen. Laparoscopy is an important tool for staging and has proven to be more reliable than CT scanning in detecting spread of cancer to the liver and the lining of the abdomen (peritoneum).

Bronchoscopy: Bronchoscopy refers to the examination of the lungs and can be helpful in identifying involvement of the trachea when the primary cancer is advanced and located in the upper part of the esophagus.

Endosonography: Endosonography refers to an ultrasound test performed through an endoscope. Ultrasound tests utilize sound waves to detect different densities of tissue, including cancer. Endosonography can detect spread of cancer into various layers of the stomach, adjacent organs and lymph nodes better than CT scanning.

Positron emission tomography (PET): Positron emission tomography (PET) scanning has also been used to improve the detection of cancer in lymph nodes. One characteristic of living tissue is the metabolism of sugar. Prior to a PET scan, a substance containing a type of sugar attached to a radioactive isotope (a molecule that spontaneously emits radiation) is injected into the patient’s vein. The cancer cells “take up” the sugar and attached isotope, which emits positively charged, low energy radiation (positrons). The positrons react with electrons in the cancer cells, which creates the production of gamma rays. The gamma rays are then detected by the PET machine, which transforms the information into a picture. If no gamma rays are detected in the scanned area, it is unlikely that the mass in question contains living cancer cells. In one clinical study, PET scanning detected 85% of lymph nodes involved with cancer, which was significantly better than the detection rate with CT scanning.

In order to learn more about the most recent information available concerning the treatment of esophageal cancer, click on the appropriate stage…”

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4.      http://news.cancerconnect.com/cancer/newly-diagnosed/

“…Newly Diagnosed

A new diagnosis of cancer can be a shock, making you feel out of control and overwhelmed. Getting informed can help alleviate these feelings. Remember, very few cancers require emergency treatment; you have time to learn about your diagnosis and treatment options, ask questions, and get a second opinion. This section is designed to help you address your initial questions before you move forward with your treatment.

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5.      http://news.cancerconnect.com/cancer/newly-diagnosed/questions-to-ask/

 “…Your doctor and nurse are your best sources of information, but you must remember to ask questions. There is no such thing as a dumb question. Don’t be afraid to ask anything that is on your mind. To make the most of your opportunities to learn from your health care providers, read as much as you can and make a list of questions before each appointment. Also, ask family, friends, and your support team to help you remember the questions. These approaches will help you talk more effectively with your doctor or nurse. Finally, you or your caregiver should consider taking notes during your visit to ensure you remember what you learned…”

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6.      http://news.cancerconnect.com/her2-testing-routinely-performed-patients-gastric-cancer/

“…A key point about the new guidelines is that they recommend HER2 testing during the initial diagnosis of advanced GEA and at important other points during treatment…”

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7.       https://www.oncolink.org/cancers/gastrointestinal/esophageal-cancer/all-about-esophageal-cancer

“…How is esophageal cancer diagnosed and staged?

Diagnosis

Work up of an esophageal cancer usually starts after the patient presents with symptoms. In the case of esophageal cancer, this usually means problems with swallowing. The first step is to establish the diagnosis of esophageal cancer. Initial tests sometimes include a barium swallow, where the person swallows barium to permit visualization of the contours of the esophagus on x-rays. Generally, the esophagus is smooth, and if there is a defect in the smooth contour of the esophagus, this may suggest a cancer.

An endoscopy is commonly done when people first present with symptoms. Using endoscopy, the area of concern in the esophagus can be viewed directly with the fiber-optic camera, and the location of the abnormality, the presence or absence of bleeding, and the amount of obstruction can all be seen. Endoscopy also allows a biopsy to be performed. Once a biopsy is performed, the pathologist can determine if there is esophageal cancer, and whether it is adenocarcinoma or squamous cell carcinoma.

Once the diagnosis has been established, it is important to determine how much cancer is present in the esophagus, as well as whether it has spread to any other parts of the body (metastasis). This is known as cancer staging and plays an important role in selecting the optimal treatment for the cancer.

If your doctor suspects that the tumor may have grown into the trachea, a bronchoscopy may be ordered, which allows the airways to be visualized.

The standard of care today would also include performing an ultrasound during the endoscopy, called an endoscopic ultrasound examination (EUS).

This allows for the prediction of how much of the esophageal wall is involved by tumor and the presence of enlarged lymph nodes that are involved with spread of tumor.

A CT ("CAT") scan is also usually done to determine the amount of disease in the chest, though it is seemingly less accurate than the EUS.

The CT scan should include imaging through the upper abdomen so that the liver and lymph nodes in the area of the stomach can be visualized. Other, more routine tests done before treatment include blood screening tests, to insure that overall blood counts are within normal limits, and that a patient's liver, kidneys, and overall health are normal. Other tests may also be included, as symptoms require. Granted, that is a lot of tests, though all are important to offer the best individual treatment for every person…

Staging

After all of these tests are performed, the stage of the cancer is determined. The staging of a cancer describes how much cancer has grown within the esophagus as well as whether it has spread. This is extremely important in terms of what treatment is offered to each individual patient. Before the staging systems are introduced, first some background on how cancers grow and spread, and therefore advance in stage.

Cancers cause problems because they spread and can disrupt the functioning of normal organs. One way esophageal cancer can spread is by local extension to invade through the normal structures in the chest and into adjacent structures. These include the trachea, the diaphragm, and even into the large veins and arteries emanating from the heart.

All cancers can spread via local extension, and it is very common for esophageal cancer to spread quite extensively locally before diagnosis is obtained. This is what causes the many symptoms of esophageal cancer, including difficulties with swallowing, cough, bleeding, and subsequent fatigue and weight loss due to malnutrition.

Esophageal cancer can also spread by accessing the lymphatic system.

The lymphatic circulation is a complete circulation system in the body (somewhat like the blood circulatory system) that drains into various lymph nodes.

When cancer cells access this lymphatic circulation, they can travel to lymph nodes and start new sites of cancer. This is called lymphatic spread. Within the wall of the esophagus, there is an extensive network of lymphatic channels, hence a large proportion of patients present with lymph nodes already involved with cancer.

The first lymph nodes that cancer cells spread to are the lymph nodes found just along the side of the esophagus (peri-esophageal lymph nodes).

Cancer can then spread into the middle of the chest (mediastinal lymph nodes) and into the areas of the neck above the collar bone (supraclavicular lymph nodes) or into the abdomen (peri-gastric and celiac lymph nodes), depending where the primary esophageal cancer is located.

Esophageal cancers can also spread through the bloodstream. Cancer cells gain access to distant organs via the bloodstream and the tumors that arise from cells that travel to other organs are called metastases. Cancers of the esophagus generally spread locally or to lymph nodes before spreading distantly through the bloodstream.

The staging system used in esophageal cancer is designed to describe the extent of disease within the esophagus, in the surrounding lymph nodes, and distantly.

The staging system used to describe esophageal tumors is the "TNM system", as described by the American Joint Committee on Cancer. The TNM systems are used to describe many types of cancers.

They have three components:

T-describing the extent of the "primary" tumor (the tumor in the esophagus itself);

N-describing the spread to the lymph nodes;

M-describing the spread to other organs (i.e.-metastases).

The staging for esophageal cancer also includes histologic grade (how the cells appear under the microscope). The location of the tumor is also considered in squamous cell esophageal cancers.

The T, N and M are combined to come up with a stage from 0-IV, with IV being the most advanced.

AJCC Classification of Carcinoma of the Esophagus and Esophagogastric Junction, 7^th. Ed., 2010

Primary T (T)

TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
T1a	High grade dysplasia
T1	Tumor invades lamina proproa, muscularis mucosae, or mucosa
T1a	Tumor invades lamina propria or muscularis mucosae
T1b	Tumor invades submucosa
T2	Tumor invades muscularis propria
T3	Tumor invades adventitia
T4	Tumor invades adjacent structures
T4a	Resectable tumor invading pleura, pericardium, or diaphragm
T4b	Unresectable tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc.

Regional Lymph Nodes (N)

NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	Metastasis in 1-2 regional lymph nodes
N2	Metastasis in 3-6 regional lymph nodes
N3	Metastasis in seven or more regional lymph nodes

Distant Metastasis (M)

M0	No distant metastasis
M1	Distant metastasis

Histologic Grade (G)

GX	Grade cannot be assessed-stage grouping as G1
G1	Well differentiated
G2	Moderately differentiated
G3	Poorly differentiated
G4	Undifferentiated-stage grouping as G3 squamous

 

Anatomic Stage/Prognostic Groups-Squamous Cell Carcinoma

(or mixed histology including a squamous component or NOS)

Stage	T	N	M	Grade	Tumor Location**
Stage 0	T1s	N0	M0	1,X	Any
Stage IA	T1	N0	M0	1,X	Any
Stage IB	T1	N0	M0	2-3	Any
	T2-3	N0	M0	1,X	Lower, X
Stage IIA	T2-3	N0	M0	1,X	Upper, mid
	T2-3	N0	M0	2-3	Lower, X
Stage IIB	T2-3	N0	M0	2-3	Upper, mid
	T1-2	N1	M0	Any	Any
Stage IIIA	T1-2	N2	M0	Any	Any
	T3	N1	M0	Any	Any
	T4a	N0	M0	Any	Any
Stage IIIB	T3	N2	M0	Any	Any
Stage IIIC	T4a	N1-2	M0	Any	Any
	T4b	Any	M0	Any	Any
	Any	N3	M0	Any	Any
Stage IV	Any	Any	M1	Any	Any

 

** Location of the primary cancer site is defined by the position of the upper (proximal) edge of the tumor in the esophagus

Anatomic Stage/Prognostic Groups-Adenocarcinoma

Stage	T	N	M	Grade
Stage 0	Tis (HGD)	N0	M0	1, X
Stage IA	T1	N0	M0	1-2, X
Stage IB	T1	N0	M0	3
	T2	N0	M0	1-2, X
Stage IIA	T2	N0	M0	3
Stage IIB	T3	N0	M0	Any
	T1-2	N1	M0	Any
Stage IIIA	T1-2	N2	M0	Any
	T3	N1	M0	Any
	T4a	N0	M0	Any
Stage IIIB	T3	N2	M0	Any
Stage IIIC	T4a	N1-2	M0	Any
	T4b	Any	M0	Any
	Any	N3	M0	Any
Stage IV	Any	Any	M1	Any

 

…Radiation therapy makes the use of high energy x-rays to kill cancer cells. It does this by damaging the DNA in tumor cells.

 Normal cells in our body can repair radiation damage much quicker than tumor cells, so while tumor cells are killed by radiation, many normal cells are not. This is the basis for the use of radiation therapy in cancer treatment. Radiation is delivered using large machines that produce the high energy x-rays. After radiation oncologists set up the radiation fields ("radiation fields" are the areas of the body that will be treated by radiation), treatment is begun.

Radiation is given 5 days a week for approximately 5-7 weeks at a radiation treatment center. The treatment takes just a few minutes each day and is completely painless. It is designed to kill tumor cells in the area that is at risk to contain cancer cells, whether it is in the esophagus or the regional lymph nodes. Typical side effects mainly include a sore throat, skin irritation (resembling a sunburn), and fatigue.

Chemotherapy is defined as medications that are used to kill tumor cells.

The large advantage in using chemotherapy is that it travels throughout the entire body. Hence, if some tumor cells have spread outside of what surgery or radiation can treat, they can potentially be killed by chemotherapy.

The additional important benefit from chemotherapy in the treatment of esophageal cancer is that it works with radiation, resulting in more killing of cancer cells. Similar to radiation, some normal cells are damaged during treatment, resulting in side effects. The exact side effects depend on which type of chemotherapy is used, though fatigue, some nausea, and a decrease in blood counts can result from commonly used chemotherapy agents.

There is some debate as to the optimal order in which to deliver these treatments to the esophagus. Different institutions may vary the order in which they use these three modalities in the attempt to cure esophageal cancer.

Many will use radiation therapy combined with chemotherapy pre-operatively (prior to surgery).

Combination platinum based chemotherapy (using several medications including one from the platinum family) is used; combinations include:

5FU and cisplatin or oxaliplatin, carboplatin and paclitaxel, cisplatin, leucovorin, capecitibine, irinotecan and etoposide. These medications are used in both pre and post-operative chemotherapy regimens.

The advantage of using chemo and radiation together is that it often results in the decrease in the size of the tumor that needs to be removed.

However, the toxicity from combining radiation with chemotherapy can cause more side effects than if given alone. It is very important for people to maintain their nutrition so they can heal well in anticipation of surgery, which usually takes place around 4-8 weeks after chemo/radiation. Surgery after chemotherapy and radiation appears to improve the local control further.

However, some centers recommend post-operative treatment. The main advantage of this method is that surgery can be performed in an unirradiated field, allowing for a better surgical technique.  Surgical removal of the entire tumor is ideal for the treatment of esophageal cancer.

In some cases, the person is too sick to undergo surgery, or may choose not to undergo surgery. In these cases, a combined, concurrent use of chemotherapy with radiation therapy is usually employed. This method has been proven better than radiation alone, and some think it can reach cure rates comparable to surgery, however this is still being studied.

The combined use of radiation therapy and chemotherapy has toxicities as well; mainly irritation of the esophagus making it extremely painful and hence difficult to swallow towards the end of treatment. Some people are too sick to tolerate combined treatment and are treated with radiation or chemotherapy alone.

Advanced esophageal cancer is treated with chemotherapy using single agents or a combination of agents, including paclitaxel, carboplatin, cisplatin, 5FU, irinotecan, epirubicin, capecitabine, and docetaxel.

Targeted therapies are also being used in patients with advanced or metastatic esophageal cancer. Two of those agents are Herceptin (targets/blocks Her2neu receptor) and ramucirumab (which blocks vascular endothelial growth factor (VGEF) receptor). Other investigational agents that are being evaluated in clinical trials are targeting endothelial growth factor receptor (EGFR) and MET/hepatocyte growth factor receptors.

Alternatively, people can be treated with techniques to help alleviate the symptoms in the event that they are too sick to undergo radiation or chemotherapy. Advanced esophageal cancer that is incurable often leaves the patient with difficulty swallowing or unable to swallow at all. Chest pain and bleeding are other common symptoms that can require palliation (treatment to relieve symptoms, not necessarily treat the cancer).

Radiation therapy is often used to achieve palliation, with varying success; especially with obstruction - studies have reported improvement in swallowing in approximately 80% of patients.

Mechanical stents can be placed, a "balloon" used to temporarily open the esophagus, or laser removal of tumor can be attempted. These can achieve symptom relief quicker, though they have their risks and are only temporary measures.

As different treatments may be effective in treating a patient's cancer, it is good to be well-informed.

Esophageal cancer is treated by a multidisciplinary team that includes: medical oncologists, surgical oncologist, radiation oncologist, advanced practice providers, gastroenterologist and nutritionist. The medical oncologist often leads the team with the goal to maximize chance of cure and function after treatment…”

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