Palliative treatment of esophageal cancer

Palliative interventions for advanced esophageal cancer include surgery, radiation therapy, chemotherapy, chemoradiation, endoscopic procedures, and combinations of the above. Palliative esophagectomy or bypass procedures are difficult to justify in these patients because their life expectancy is so short. Palliative external beam radiation to doses of 50 to 60 Gy is successful in 50% to 70% of patients. The addition of brachytherapy may improve these results. One third to one half of patients treated with radiation develop benign or malignant stricture. Although response rates to combination chemotherapy are only 50% at best, the majority of patients do have improvement of dysphagia. These regimens are commonly used as part of a multidisciplinary approach with radiation and/or surgery, rather than as a sole modality of treatment. Chemoradiation regimens result in better survival than treatment with radiation alone, and provide palliation of dysphagia in up to 90% of patients. Although acute toxicity of chemoradiation is more severe than radiation alone, this is of limited duration. Chemoradiation may be the treatment of choice for the majority of patients with locally advanced esophageal cancer. Endoscopic techniques are available that provide palliation of dysphagia. The most commonly used technique is esophageal dilatation, either alone or before performing other palliative procedures such as laser therapy or stent placement. The most significant limitation of dilatation alone is that palliation is short-lived and most patients require repeat dilatations. Esophageal stents offer a high degree of palliation, but procedure-related morbidity and mortality rates are not insignificant. Expandable metal stents are associated with few complications but tumor ingrowth through the metallic mesh is frequent. Conventional plastic stents are not affected by tumor ingrowth but can migrate. Endoscopic laser therapy also provides symptom relief and complication rates are relatively low. It is possible that a combination of laser therapy and external beam or intraluminal radiation will provide more durable palliation than laser treatment alone. BICAP tumor probes, (Circon-ACMI, Stamford, CT), which provide direct application of electrical current, are limited to treatment of tumors that are circumferential. Photodynamic therapy (PDT), which applies laser light along with a photosensitizing agent, has resulted in a high rate of palliation. Limitations of PDT include skin photosensitization requiring patients to stay out of the sun for at least 1 month following treatment, high cost of required equipment, and limited efficacy because of the shallow depth of light penetration. A variety of treatment options exist for the management of tracheo-esophageal fistulae (TEF), but only radiation therapy or bypass surgery appear to prolong survival. Radiation therapy does not appear to worsen the TEF as was commonly thought in the past, and it is likely applicable in more patients than is surgery. The challenge for the physician in palliating patients with esophageal cancer is to select therapy appropriate for a given patient, taking into account the patient's disease, coexisting medical problems, performance status, and the patient's desires.