What are the treatment options for cancer in Barrett's esophagus?

Cancer staging

After the diagnosis of cancer is confirmed by upper endoscopy with biopsy, the patient goes through tests to stage the tumor (determine as best as possible how much cancer is present). The staging tests used give a very good estimate of how deep the tumor is growing into the esophageal wall, whether it involves other chest structures (such as blood vessels or the lungs), whether it has spread to lymph nodes and whether it has spread to other organs (metastasized). Accurate staging of a tumor is important because decisions concerning how to best treat the patient's cancer will be made based on the stage of the tumor, the medical fitness of the patient as well as the patient's preference for a particular therapy, especially in the treatment of very early stage cancer.

The main tests used to stage a tumor are computerized tomography (CT) scan, positron emission tomography (PET scanning), and endoscopic ultrasound (EUS). These tests are complimentary. A CT scan is a computer enhanced x-ray and the best test to determine whether a tumor has spread to other organs. PET scans are sometimes done in cases where the CT scan is unclear. PET scans utilize radioactive tracer material which concentrates in tumors and can help identify tumor spread which is not evident on CT scans. Endoscopic ultrasound is the best test to estimate how deep the cancer is growing into the wall of the esophagus and to check the lymph nodes in the chest and upper abdomen for cancer. An endoscopic ultrasound is just like having upper endoscopy but the endoscope has an ultrasound probe in it that sends sound waves into the esophagus. These sound waves allow the doctor to make images of the layers of the esophageal wall as well as to visualize surrounding structures. From how the sound waves bounce off the wall of the esophagus, each individual layer of the esophagus can be seen. 

Stage of the cancer and likelihood of cure

Early cancers, growing no deeper than into the submucosal layer of the esophagus have a high cure rate with esophagectomy, surgical removal of the esophagus, especially those growing only into the very top layer of the esophagus called the mucosal layer.  Non-surgical endoscopic therapies are now also available for the treatment of early cancers, but how the cure-rate for the earliest stage cancers compares to esophagectomy long-term is unknown.  

The deeper a cancer invades into the esophageal wall, or if lymph nodes are positive for cancer, the less likely the patient will be cured by esophagectomy. Large or deeply invasive cancers and cancers with positive lymph nodes cannot be cured by endoscopic therapies. Patients who have cancers growing deep into the wall of the esophagus may also be offered chemotherapy and radiation therapy either alone or in combination with esophagectomy.

How will my doctor develop a cancer treatment plan for me?

After an esophageal cancer has been diagnosed and staged, a treatment plan will be developed. If the cancer seems to be very superficial (very early stage) based on EUS and CT scan criteria, you can consider a non-surgical endoscopic therapy such as endoscopic mucosal resection, photodynamic therapy or a combination of these two therapies performed by an experienced gastroenterologist (GI doctor). You should also see an experienced esophageal surgeon who operates at a large volume specialty center to hear about the risks and benefits of  esophagectomy (surgical removal of the esophagus) as treatment for an early stage cancer. Which of these treatments your doctor recommends and you decide to undergo will depend on your overall medical health and your personal desire for a particular therapy after hearing about the risks and benefits of both endoscopic therapy and surgery. 

If staging tests show that the cancer is deeper than early stage or that there may be positive lymph nodes but no spread of the cancer to other organs such as the liver or lungs, then esophagectomy is the usual recommended therapy for patients in otherwise good medical health. There are several types of surgeries which can be performed and what type of surgery is performed  depends on the location of the cancer and the experience of the surgeon in performing that surgery. If the cancer is too large for immediate surgery, but is still considered potentially curable, your doctor may recommend the use of neoadjuvant therapy. Neoadjuvant therapy is when chemotherapy and/or radiation therapy is given before surgery in an attempt to make the tumor smaller and allow the surgeon to completely remove it. The best approach to neoadjuvant therapy is not currently known and is a source of ongoing studies.

If a very large cancer is diagnosed, it has spread to other organs or based on a medical health assessment, it is considered too dangerous to do the surgery, palliative therapy (treatment not intended to cure but rather to improve symptoms such as difficulty in swallowing) may be recommended. Palliative options include stents (hollow pipes which open up the food passage way), photodynamic or other ablative therapy. Radiation and chemotherapy may also be recommended. Chemotherapy can sometimes shrink tumors even if they have spread to organs such as the liver. Cancer specialists called oncologists, especially one who specializes in esophageal cancer, can help design treatment plans which are of the most potential benefit to you and take into account your health, the stage of your disease and your own preference for treatment choices.