Treatments for stage 4 esophageal cancer

The following are treatment options for stage 4 esophageal cancer. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.

Treatment for stage 4 esophageal cancer focuses on relieving symptoms, such as difficulty swallowing and pain, and improving your quality of life.

Endoscopic treatments for stage 4 esophageal cancer are offered to relieve pain or remove a blockage. You may be offered the following endoscopic treatments.

• radiofrequency ablation (RFA)
• laser surgery
• photodynamic therapy (PDT)
• esophageal dilation
• esophageal stent
• electrocoagulation or argon plasma coagulation (may not be available in all Canadian treatment centres)
• placement of a feeding tube

Chemotherapy is sometimes offered for stage 4 esophageal cancer. Adenocarcinoma tumours of the esophagus respond better to chemotherapy than squamous cell carcinoma (SCC) tumours.

Chemoradiation is chemotherapy combined with radiation therapy. The 2 treatments are given during the same time period. It may be used before surgery for stage 4 esophageal cancer. Unfortunately, surgery is not usually an option at this stage.

The most common chemotherapy drugs used to treat stage 4 esophageal cancer are:

• capecitabine (Xeloda)

• cisplatin and capecitabine
• cisplatin and etoposide (Vepesid)
• cisplatin and fluorouracil
• cisplatin and irinotecan
• carboplatin and fluorouracil
• carboplatin and irinotecan
• carboplatin and paclitaxel
• epirubicin, carboplatin and fluorouracil
• epirubicin, carboplatin and capecitabine
• epirubicin, cisplatin and capecitabine
• epirubicin, cisplatin and fluorouracil
• fluorouracil and leucovorin
• docetaxel (Taxotere), oxaliplatin, fluorouracil and leucovorin
• oxaliplatin, fluorouracil and leucovorin
• oxaliplatin and capecitabine

Targeted therapy drugs may be used to treat stage 4 adenocarcinoma tumours at the gastroesophageal (GE) junction. They are usually combined with chemotherapy.

Trastuzumab is used with chemotherapy drugs to treat HER2-positive tumours. The most common combinations are:

• trastuzumab, cisplatin and fluorouracil
• trastuzumab, cisplatin and capecitabine

Ramucirumab (Cyramza) is a monoclonal antibody that stops cells from using a substance called vascular endothelial growth factor (VEGF), which helps cells form new blood vessels. Without new blood vessels the cells don't get the oxygen and nutrients that they need to grow. Ramucirumab is given in combination with paclitaxel.

Immunotherapy may be used for stage 4 esophageal cancer.

Pembrolizumab( Keytruda) may be offered in combination with cisplatin and fluorouracil as the first treatment for:

• squamous cell carcinoma of the esophagus
• HER-2 negative adenocarcinoma tumours found at the gastroesophageal junction

Pembrolizumab can also be used as a first treatment in combination with cisplatin, fluorouracil and trastuzumab for HER-2 positive adenocarcinoma tumours found at the gastroesophageal junction.

Nivolumab( Opdivo) may be offered for stage 4A esophageal cancer if surgery was done to remove the tumour. It may also be offered to people who still have cancer remaining after neoadjuvant therapy with chemoradiation and surgery.

Nivolumab may be given in combination with either cisplatin and fluorouracil or carboplatin and fluorouracil for tumours at the gastroesophageal junction or adenocarcinoma tumours.

Ipilimumab( Yervoy) can be used in combination with nivolumab to treat squamous cell carcinoma tumours of the esophagus.

Radiation therapy may be offered to shrink stage 4 esophageal cancer to help with swallowing and relieve pain.

External radiation therapy directs radiation at the tumour from a machine outside of the body. It may be offered either alone or as part of chemoradiation.

Intraluminal brachytherapy uses a radioactive implant placed into the esophagus near the tumour.

Esophagectomy is surgery to remove all or part of the esophagus, as well as lymph nodes around it. In rare cases it may be offered for some people with stage 4A esophageal cancer, if the cancer has spread only to the nearby lymph nodes.

You may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don't work anymore, they're not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can't have or don't want cancer treatment.

Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.

Talk to your doctor about clinical trials open to people with esophageal cancer in Canada. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.