Multimodality Therapy for Esophageal Cancer

Achieving real improvement in the treatment outcomes for esophageal cancer has been a slow process. Many major hurdles impeding our ability to diagnose and treat the disease have been overcome in the past century. Reliable and safe anesthetic techniques for thoracic surgery, and minimizing mortality from an esophageal resection while maximizing local/regional control (to the extent that radical surgery is capable), have had a significant impact in placing surgery at the forefront of esophageal cancer therapy, yet the breakthrough discovery that would allow us to cure a significant percentage of people with this diagnosis still eludes us. Radical surgery has reached a ceiling of effectiveness, and the field is now in the process of backing away from larger resections in favor of minimizing trauma and operative morbidity. We have witnessed nominal improvements in survival outcomes over the past few decades, but often these gains can be attributed to avoiding mortality rather than salvaging sicker patients in more advanced stages. Better pretreatment staging studies and knowledge about the efficacy of local therapies have led to more appropriate patient selection, avoiding surgery in those who are at high risk for perioperative mortality or distant failure. Although this gives the impression that we are improving, it leaves behind the patients who are not salvageable with existing local/regional therapies. Even in patients with disease that is limited to local/regional stage, we have learned that, in most cases, radical resection with or without other forms of local/regional therapy is not adequate to cure people. Distant recurrence continues to be the main cause of death in patients with esophageal cancer.