ON THIS PAGE: You will learn about the different types of treatments doctors use for people with esophageal cancer. Use the menu to see other pages.
This section explains the types of treatments that are the standard of care for esophageal cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, you are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections.
How esophageal cancer is treated (updated 08/2021)
In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.
The common types of treatments used for esophageal cancer are described below. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.
Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision-making.” Shared decision-making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision-making is particularly important for esophageal cancer because there are different treatment options. Learn more about making treatment decisions.
For a tumor that has not spread beyond the esophagus and lymph nodes, doctors often recommend combining different types of treatment: radiation therapy, chemotherapy, and surgery. Sometimes, chemotherapy and radiation therapy are combined in an approach called “chemoradiotherapy.” The order of treatments varies, and several factors are considered, including the type of esophageal cancer.
For locally advanced esophageal cancer, ASCO recommends a treatment plan that combines different types of treatments
For squamous cell cancer, chemoradiotherapy is commonly recommended as the first treatment. Surgery may be used afterwards depending on how well chemoradiotherapy worked. Recent studies show using chemoradiotherapy before surgery is better than surgery alone. ASCO recommends chemoradiotherapy before surgery for all people with locally advanced esophageal squamous cell cancer. In some patients, this treatment may send the cancer into remission, and surgery may not be needed immediately. In those who receive chemoradiotherapy and surgery, immunotherapy (see below) may be recommended if tumor cells are still found in the tissue removed during surgery. Some people may not be able to receive radiation therapy. These patients can receive chemotherapy alone before surgery.
For adenocarcinoma, the most common treatment in the United States is chemoradiotherapy followed by surgery. Surgery is almost always recommended after chemoradiotherapy, unless there are factors that increase the risks from surgery, such as a patient's overall health. For locally advanced esophageal adenocarcinoma, ASCO recommends chemoradiotherapy before surgery or chemotherapy before and after surgery. After chemoradiotherapy and surgery, if tumor cells are found in the tissue removed during surgery, immunotherapy (see below) may be recommended. For some people, surgery is not an option. In that case, chemoradiotherapy alone is the recommended treatment. When chemotherapy and radiation therapy are combined, there can be more severe side effects. But this treatment combination can be more effective in certain situations. It's important to discuss with your doctor which treatment options are best for you.
This information is based on the ASCO guideline, “Treatment of Locally Advanced Esophageal Carcinoma.” Please note that this link takes you to another ASCO website.
For advanced or metastatic esophageal cancer, treatment usually involves radiation therapy, chemotherapy, and other therapies using medication.
Read below for more details about each type of treatment option for esophageal cancer.
Physical, emotional, and social effects of cancer
Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report that they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.
Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan being recommended. You should also talk about the possible side effects of the specific treatment plan and palliative care options. Many patients also benefit from talking with a social worker and participating in support groups. Ask your doctor about these resources, too.
During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.
Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.
Surgery (updated 08/2021)
Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. A surgical oncologist is a doctor who specializes in treating cancer using surgery. Surgery has traditionally been the most common treatment for esophageal cancer. However, currently, surgery without previous chemotherapy or chemoradiotherapy is used as the main treatment only in specific situations.
For most people with locally advanced esophageal cancer, ASCO recommends chemoradiotherapy or chemotherapy before surgery because combined therapy has been shown to help people live longer (see above). After chemoradiotherapy and surgery, immunotherapy may be recommended if tumor cells are still found in the tissue removed during surgery. If surgery is not possible, the best treatment option is often a combination of chemotherapy and radiation therapy.
The most common surgery to treat esophageal cancer is called an esophagectomy, where the doctor removes the affected part of the esophagus and then connects the remaining healthy part of the esophagus to the stomach so that the patient can swallow normally. If that is not possible, part of the intestine may sometimes be used to make the connection. The surgeon also removes lymph nodes around the esophagus.
Before surgery, talk with your health care team about the goals of care and possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.
Surgery for palliative care
In addition to surgery to treat the disease, surgery may be used to help people eat and relieve symptoms caused by the cancer. This is called palliative surgery. To do this, surgeons and doctors called gastroenterologists, who specialize in the gastrointestinal tract, can:
Put in a feeding tube so that a person can receive nutrition directly into the stomach or intestine. A tube that passes nutrition directly into a person's stomach is called a percutaneous endoscopic gastrostomy or PEG. A feeding tube that passes nutrition directly into a person's intestine is called a percutaneous endoscopic transgastric jejunostomy or PEJ. This may be done before chemotherapy and radiation therapy is given to make sure that the person can eat enough food to maintain their weight and strength during treatment.
Create a bypass, or new pathway, to the stomach if a tumor blocks the esophagus but cannot be removed with surgery. This procedure is rarely used.
People who have had trouble eating and drinking may need intravenous (IV; into a vein) feedings and fluids for several days before and after surgery, as well as antibiotics to prevent or treat infections. Patients are taught special coughing and breathing exercises to keep their lungs clear.
The following treatments use a long, flexible tube called an endoscope (see Diagnosis) to treat the symptoms associated with esophageal cancer and to manage side effects caused by the tumor.
Endoscopy and dilation. This procedure expands the esophagus. It may have to be repeated if the tumor grows.
Endoscopy with stent placement. This procedure uses an endoscopy to insert a stent in the esophagus. An esophageal stent is a metal, mesh device that is expanded to keep the esophagus open.
Electrocoagulation. This type of palliative treatment helps destroy cancer cells by heating them with an electric current. This is sometimes used to help relieve symptoms by removing a blockage caused by the tumor.
Cryotherapy. This is a type of palliative treatment that uses an endoscope with a probe attached that can freeze and remove tumor tissue. It can be used to reduce the size of a tumor to help a patient swallow easier.
Other, less-common techniques include photodynamic therapy and laser therapy. In photodynamic therapy, a light-sensitive substance called a photosensitizer is given by vein. Then, a laser is then directed at the esophageal lesions using an endoscope. In laser surgery, a laser is used to burn the esophageal lesions through an endoscope.
Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body.
When radiation treatment is given directly inside the body, it is called internal radiation therapy or brachytherapy. For esophageal cancer, this involves temporarily inserting a radioactive wire into the esophagus using an endoscope (see "Endoscopic therapy," above and in Diagnosis).
Proton beam therapy is being studied in clinical trials for esophageal cancer. Proton beam therapy is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy cancer cells.
Side effects from radiation therapy may include fatigue, mild skin reactions, soreness in the throat and esophagus, difficulty or pain with swallowing, upset stomach, nausea, and loose bowel movements. Most side effects go away soon after treatment is finished.
Learn more about the basics of radiation therapy.
Therapies using medication
Treatments using medication are used to destroy cancer cells. Medication may be given through the bloodstream to reach cancer cells throughout the body. When a drug is given this way, it is called systemic therapy. Medication may also be given locally, which is when the medication is applied directly to the cancer or kept in a single part of the body.
This type of medication is generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication. Medications are often given through an intravenous (IV) tube placed into a vein using a needle or as a pill or capsule that is swallowed (orally). If you are given oral medications, be sure to ask your health care team about how to safely store and handle it.
The types of medications used for esophageal cancer include:
Each of these types of therapies are discussed below in more detail. A person may receive 1 type of medication at a time or a combination of medications given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications.
It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications, causing unwanted side effects or reduced effectiveness. Learn more about your prescriptions by using searchable drug databases.
Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells.
A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or a combination of different drugs given at the same time. As explained above, chemotherapy and radiation therapy are often given at the same time to treat esophageal cancer, called chemoradiotherapy.
The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, nerve problems, loss of appetite, and diarrhea. These side effects usually go away after treatment is finished.
Learn more about the basics of chemotherapy.
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.
Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.
Targeted therapy for esophageal cancer includes:
HER2-targeted therapy. For esophageal cancer, the targeted therapy trastuzumab (Herceptin, Ogivri) may be used along with chemotherapy as a first treatment for metastatic esophageal adenocarcinoma. Trastuzumab deruxtecan (Enhertu) is also approved as a first treatment for metastatic esophageal adenocarcinoma. This combines a drug that is similar to trastuzumab with a strong chemotherapy. For metastatic or recurrent gastroesophageal cancer that is HER2 positive, ASCO, ASCP, and CAP recommend a combination of chemotherapy and HER2-targeted therapy. If the cancer is HER2 negative, HER2-targeted therapy is not a treatment option for you and your doctor will give you other options for treating the cancer.
Anti-angiogenesis therapy. The targeted therapy ramucirumab (Cyramza) may be a treatment option if first-line therapy, or the first treatments given, has not worked. Ramucirumab is a type of targeted therapy called an anti-angiogenic. It is focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor. Ramucirumab is most commonly given with paclitaxel, a type of chemotherapy (see above), but can also be given by itself.
Talk with your doctor about possible side effects for each specific medication you are prescribed and how they can be managed.
Immunotherapy (updated 08/2021)
Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.
There are 2 types of immunotherapy drugs that are approved to treat both adenocarcinoma and squamous cell carcinoma of the esophagus and the gastroesophageal junction, which is cancer that grows where the stomach and esophagus meet. Pembrolizumab (Keytruda) and nivolumab (Opdivo) are both checkpoint inhibitors that target the PD-1/PD-L1 pathway (see Diagnosis).
Pembrolizumab (Keytruda)is approved in the following situations:
As a first-line treatment in combination with chemotherapy for incurable locally advanced or metastatic esophageal and gastroesophageal junction adenocarcinoma and squamous cell carcinoma, regardless of PD-L1 expression.
As a first-line treatment in combination with chemotherapy and trastuzumab for HER2-positive incurable locally advanced or metastatic esophageal and gastroesophageal junction adenocarcinoma and squamous cell carcinoma, regardless of PD-L1 expression.
As a second-line treatment for esophageal squamous cell carcinoma that tests CPS positive at 10% or higher. CPS stands for "combined positive score" and it is a way to measure how many cells express the PD-L1 protein.
It is also approved to treat gastroesophageal junction adenocarcinoma that tests positive for MSI-H or has mismatch repair deficiency after 1 or more chemotherapy treatments have not stopped the cancer.
Nivolumab (Opdivo)is approved in the following situations:
As a first-line treatment in combination with chemotherapy for esophageal or gastroesophageal junction adenocarcinoma, regardless of PD-L1 expression.
As a second-line treatment for esophageal squamous cell carcinoma, regardless of PD-L1 expression.
As a post-surgery adjuvant treatment after chemotherapy, radiation, and surgery in esophageal and gastroesophageal adenocarcinoma and squamous cell carcinoma if any cancer cells remain in the tissue removed during surgery. Some research suggests that people with tumors with higher PD-L1 expression may have a greater benefit from adjuvant nivolumab, but this requires further study.
Metastatic esophageal cancer
If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.
For metastatic esophageal cancer, palliative or supportive care is very important to help relieve symptoms and side effects. The goal of treatment is usually to lengthen a person’s life, while easing symptoms such as pain and problems with eating. Your treatment plan may include chemotherapy, as well as radiation therapy to help relieve pain or discomfort. For example, an esophageal stent, laser therapy, photodynamic therapy, or cryotherapy may help keep the esophagus open (see above).
For most people, a diagnosis of metastatic cancer is very stressful and difficult. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, such as through a support group or other peer support program.
Remission and the chance of recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.
A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
If the cancer returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatments described above such as surgery, chemotherapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.
People with recurrent cancer sometimes experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope. Learn more about dealing with cancer recurrence.
If treatment does not work
Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for some people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.
After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.
The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Use the menu to choose a different section to read in this guide.