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Stage 4 Esophageal Cancer
Patients with stage 4 esophageal cancer have metastatic cancer that has spread to distant sites.
The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival.
The following is an overview of the treatment of stage 4 esophageal cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied to your situation. The information on this web-site is intended to help educate you about your treatment options and to create discussion to help in the decision-making process with your treatment team.
Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news to learn about new treatments and the results of clinical trials.
Optimal treatment of patients with stage 4 esophageal cancer often requires more than one therapeutic approach. Thus, it is important for patients to be treated at a medical center that can offer multidisciplinary treatment involving medical oncologists, radiation oncologists, interventional radiologists, surgeons, gastroenterologists and nutritionists.
The predominant symptom of esophageal cancer is dysphagia, which simply means difficulty in swallowing food and liquids. There are specific treatments that can be administered that can result in short-term benefit and improvement in nutrition. Current treatment approaches are primarily directed at controlling the symptoms of cancer and prolonging survival. A number of treatment options are currently utilized alone or in combination to achieve optimal results.
Surgery for Palliation
Patients with stage 4 esophageal cancer often have widespread cancer at the time of diagnosis and cannot be cured with surgery.
Single chemotherapy drugs such as Platinol®, fluorouracil, Mutamycin®, doxorubicin, and Ellence® can result in clinical remissions in patients with esophageal cancer. Historically, standard chemotherapy treatment regimens often utilized Platinol®, flourouracil and Ellence® or Mutamycin®. Recent studies indicate that taxanes (paclitaxel and Taxotere®) may be the most active single chemotherapy drugs for the treatment of esophageal cancer, with complete remissions occurring in up to 15% of patients. Other agents that have been or are being evaluated include Camptosar® and Gemzar®. All current clinical trials involve various combinations of drugs.
Camptosar® is another new chemotherapy drug with activity against cancers of the gastrointestinal tract. In one study,
Other Treatment Modalities
Many other treatment modalities are utilized to prolong survival and quality of life for patients with esophageal cancer.
Thermal Laser: Thermal laser coagulation performed by endoscopy can provide temporary relief of dysphagia. Laser ablation appears to be most helpful for treating polypoid cancers that grow into the esophagus causing occlusion. Laser treatment is less effective for upper esophageal cancers or cancers of the gastroesophageal junction. A multi-center clinical trial has compared photodynamic laser therapy to thermal laser ablation for the palliation of patients with esophageal cancer who experience difficulty swallowing food. In general, photodynamic laser therapy was more effective than thermal laser treatment.
Photodynamic Treatment: Photodynamic ablation has been used for the palliation of patients with esophageal cancer. Photodynamic treatment involves injection of a light sensitizer into a vein, which is then taken up by cells. A laser is then directed at the cancer cells. The reaction between the laser and the light sensitizer destroys the cells.
Esophageal Dilatation: Frequently, after the administration of chemotherapy, radiation therapy, laser or photodynamic treatment, the area of the esophagus with cancer can be constricted or narrowed. Narrowing of the esophagus may be due to recurrent cancer or to treatment induced strictures or both. Relief of this constriction by dilation can temporarily improve swallowing. During esophageal dilation, a physician uses endoscopic or fluoroscopic guidance to pass flexible dilators (mercury filled rubber tubes) through the mouth. Increasing diameters of dilators, called bougies, are gradually introduced until the difficulty in swallowing resolves.
Esophageal Stents or Prostheses: Stents are rigid tubes that stay in the esophagus to keep it open. Self-expanding metallic stents were thought to be preferable to rigid stents for maintaining an open esophagus.
Possibilities to Improve Treatment
The progress that has been made in the treatment of esophageal cancer has resulted from improved patient and physician participation in clinical studies. Future progress in the treatment of esophageal cancer will result from continued participation in appropriate studies. Currently, there are several areas of active exploration aimed at improving the treatment of esophageal cancer.
New Chemotherapy Regimens: Development of new multi-drug chemotherapy treatment regimens that incorporate new or additional anti-cancer therapies is an active area of clinical research carried out in phase II clinical trials. These studies are performed in patients with stage 4 or recurrent esophageal cancer.
Multiple Drug Resistance Inhibitors: Esophageal cancer can be drug resistant at the outset of treatment or develop drug resistance after treatment. Several drugs are being tested to determine if they will overcome or prevent the development of multiple drug resistance in esophageal and other cancers.
Gene Therapy: Currently, there are no gene therapies approved for the treatment of esophageal cancer. Gene therapy is defined as the transfer of new genetic material into a cell for therapeutic benefit. This can be accomplished by replacing or inactivating a dysfunction gene or replacing or adding a functional gene into a cell to make it function normally. Gene therapy has been directed towards the control of rapid growth of cancer cells, control of cancer death or efforts to make the immune system kill cancer cells. A few gene therapy studies are being carried out in patients with esophageal cancer.
New anti-cancer therapies continue to be developed and evaluated in clinical trials. There are three phases of clinical trials before approval. See our clinical trials section for more information.
Management of Liver Metastases
When esophageal cancer spreads to the liver, it doesn’t always cause symptoms. It may be picked up by liver function tests, which are blood tests that measure certain levels of enzymes and proteins in the blood. Abnormal levels can indicate liver disease or damage.
If liver metastasis causes symptoms, they can include:
• pain or discomfort in the mid-section
• fatigue and weakness
• weight loss/poor appetite
• swelling in the legs
• a yellow tint to the skin or the whites of the eyes
In addition to liver function tests, doctors use imaging tests to diagnose liver metastases. These may include MRI (magnetic resonance imaging), CT scan (computed tomography), ultrasound, and/or PET scan (positron emission tomography). Sometimes, a combined PET/CT scan is used.
Your doctor also may recommend getting a sample of the suspicious area(s) for examination under a microscope (biopsy). He or she may involve an interventional radiologist to obtain precise and minimally invasive imaging.
Liver Directed Therapies: There are numerous liver directed therapies available for those who are faced with a Stage 4 esophageal cancer diagnosis with liver metastases or esophageal cancer that has spread to the liver. These therapies are dependent on the size, number, and location of the liver tumors. These liver directed therapies may include chemoembolization, cryoablation, cyberknife, hepatic arterial infusion, liver resection, liver transplant, proton beam therapy, radioembolization or SIRT, radiofrequency ablation, or SBRT. You can learn more on our treatment page under liver directed therapies.
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