Stomach and oesophageal cancer

Treatment for oesophageal cancer

The most important factor in planning treatment for oesophageal cancer is the stage of the disease. Your treatment will also depend on your age, medical history and general health.

Oesophageal cancer that is found early can generally be treated successfully with surgery. If the cancer has spread, you will usually also have chemotherapy and/or radiotherapy.

Cancer care pathways

For an overview of what to expect during all stages of your cancer care, read or download the What To Expect guide for oesophoagogastric or stomach and oesphageal cancers (also available in Arabic, Chinese, Greek, Hindi, Italian, Tagalog and Vietnamese – see details on the site). The What To Expect guide is a short guide to what is recommended for the best cancer care across Australia, from diagnosis to treatment and beyond.

Surgery for oesophageal cancer

Surgery aims to remove all of the oesophageal cancer while keeping as much normal tissue as possible. However, it is essential to remove a small amount of healthy tissue around the cancer to reduce the risk of the cancer coming back.

The type of surgery will depend on where the tumour is growing and how advanced the cancer is. Your doctor will tell you how to prepare for surgery. For example, you may need to treat any nutritional issues before surgery or, if you are a smoker, stop smoking.

Endoscopic resection (ER)

In an endoscopic resection, the tumour is removed using a long, flexible tube (endoscope). This is the preferred option for removing very early-stage oesophageal tumours. It involves less risk and a faster recovery than an oesophagectomy (see below). This is usually a day or overnight stay procedure. Preparation and recovery are similar to endoscopy. This may be the only treatment needed for some people with early-stage oesophageal cancer.

Oesophagectomy (surgical resection)

This procedure removes the cancerous sections of the oesophagus. Depending on how far the cancer has spread, the surgeon may also remove part of the upper stomach, lymph nodes and other tissue. This is the preferred option for tumours that have spread deeper into the walls of the oesophagus or nearby lymph nodes. You will usually have chemotherapy and/or radiotherapy before an oesophagectomy to shrink large tumours and destroy any cancer cells that may have spread.

To remove the cancerous tissue, the surgeon will need to access the upper abdomen and chest. This may be done in two ways:

  • in an open oesophagectomy, the surgeon will open the chest and the abdomen with large surgical cuts
  • in a minimally invasive oesophagectomy (keyhole or laparoscopic surgery), the surgeon will make some small cuts in the abdomen and ribs, then insert a thin telescope to see inside the abdomen and chest.

The hospital stay and recovery time may be similar for both types of surgery. Laparoscopic surgery usually means a smaller scar, however, open surgery may be considered a better option in many situations.

Once the cancerous sections have been removed, the stomach is pulled up and reconnected to the healthy part of the oesophagus. This will allow you to swallow and eat relatively normally. Occasionally, if the oesophagus cannot be reconnected to the stomach, the oesophagus will be connected to the small bowel or a piece of large bowel will be used to restore swallowing.

Risks of oesophageal surgery

As with any major surgery, oesophageal surgery has risks. Complications may include: infection, bleeding, blood clots, damage to nearby organs, leaking from the connections between the oesophagus and stomach or small bowel, narrowing of the oesophagus from surgical scars, pneumonia (see below) and paralysis of the vocal cords. Some people may experience an irregular heartbeat, but this usually settles within a few days. Your surgeon will discuss these risks with you before surgery and you will be carefully monitored for any side effects afterwards.

What to expect after oesophageal surgery

When you wake up after the operation, you will be in a recovery room near the operating theatre or in the Intensive Care Unit. You can expect to spend time in the Intensive Care Unit and the High Dependency ward before being transferred to a standard ward.

The length of stay in hospital is generally 7–14 days, but it can be significantly longer if any complications occur. It generally takes 6–12 months to fully recover from this operation.

Surgery for oesophageal cancer is complex. To ensure the best outcome, it is recommended that you are treated in a hospital that regularly performs this type of surgery. Call Cancer Council 13 11 20 for information about hospitals in your area or to ask about assistance that may be available if you have to travel a long way for treatment.

Side effects after oesophageal surgery are similar to those after stomach surgery. There are some differences:

Drips and drains

In addition to the tubes listed under what to expect after stomach surgery, you will have a tube down your nose into your stomach (nasogastric tube) to drain fluids from the stomach.

Dietary changes

As with stomach surgery, you will be unable to eat or drink initially after surgery. It is common for a temporary feeding tube to be inserted at the time of your surgery. You can be given specially prepared feeding formula through this tube while the join between the oesophagus and stomach heals. Once you begin eating, it is common to start with fluids such as soup, and then move onto soft foods for a few weeks. Your surgeon or dietitian will advise when you can try eating solid foods. You may be advised to eat 6–8 small meals or snacks throughout the day. The hospital dietitian can prepare eating plans and work out whether you need any supplements to help meet your nutritional needs. See more information about eating after surgery.

Breathing problems

It is important that your pain is controlled to help avoid problems with breathing that can lead to pneumonia. To reduce the risk of pneumonia, a physiotherapist will teach you breathing or coughing exercises that help keep your lungs clear. You may also be taught how to use an incentive spirometer, a device you breathe into to help your lungs expand and prevent a chest infection.

For more information about ongoing effects, see managing side effects.

John's story

"My diagnosis of oesophageal cancer came as a complete surprise. Looking back, I can see that I hadn't been able to eat as much, but I put that down to getting older. It wasn't until I suddenly started vomiting out of the blue that I saw my doctor.

"A series of scans revealed I had a blockage in the gullet. An endoscopy confirmed it was oesophageal cancer. Luckily the cancer hadn't spread outside my oesophagus.

"I was admitted to hospital for chemotherapy and radiotherapy to shrink the tumour, and then went home to recover for six weeks before having surgery.

"For those three months, I was fed through a feeding tube. I found it a bit frightening at first to deal with the feeding tube at home – it was difficult to clear when it got blocked and one night I pulled it out in my sleep and had to go to hospital to have it reinserted.

"The surgery was a major procedure: it took eight hours to remove my oesophagus and reconnect my stomach. While recovering, I found the dietitians at the hospital very helpful in suggesting foods I could eat. At first I had a feeding tube, then I started on liquids and soft foods. By the time I left rehab about four weeks after the surgery, I was able to handle most foods.

"Once I was home, I followed the dietitian's advice and I haven't had many problems with eating or swallowing. I take a tablet to help prevent regurgitation, sleep sitting up, and eat small meals throughout the day.

"Although it took a while before I was game to try some foods, I now eat most things, but in small portions. You learn what foods suit you and what foods don't.

"Nearly four years after surgery, I have an almost normal lifestyle with moderation in all things."

Tell your cancer story.

Radiotherapy for oesophageal cancer

Radiotherapy (also known as radiation therapy) uses x-rays to damage or kill cancer cells so they cannot multiply. The radiation is targeted at the parts of the body with cancer. Treatment is carefully planned to do as little harm as possible to healthy body tissue.

Radiotherapy may be given alone or combined with chemotherapy. It is commonly used before surgery to shrink large tumours and destroy any cancer cells that may have spread. It is also used as the main treatment for cancers that cannot be removed surgically.

Radiotherapy is usually given externally for oesophageal cancer. Before starting treatment you will have a planning appointment that will include a CT scan. The radiotherapy team will use the images from the scan to plan your treatments. The technician may make some small permanent tattoos or temporary marks on your skin so that the same area is targeted during each treatment session.

You will usually have treatment as an outpatient once a day, Monday to Friday, for 5–7 weeks. Each treatment takes about 20 minutes and is not painful. You will lie on a table under a machine that delivers radiation to the affected parts of your body. Your doctor will advise you on the number of treatment sessions you need.

Side effects of radiotherapy

Many people will develop temporary side effects during or shortly after treatment. Your mouth and throat may become red and sore, and the lining of the oesophagus can become very sore and inflamed (oesophagitis). This can lead to painful swallowing and difficulty eating. In rare cases you may need a feeding tube to ensure you receive adequate nutrition. Other common side effects include fatigue, skin reactions, decreased appetite and weight loss. Most side effects settle around four weeks after treatment finishes.

More rarely, some people will develop long-term side effects. Radiotherapy can cause scar tissue and narrowing of the oesophagus (known as oesophageal stricture). This can make it difficult to swallow and your doctor may perform a procedure to stretch the walls of the oesophagus (dilatation). Radiotherapy can also create inflammation in the lungs, causing shortness of breath.

Ask your treatment team for advice about dealing with any side effects, call Cancer Council 13 11 20 or see Understanding Radiotherapy.

Chemotherapy for oesophageal cancer

Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells, while causing the least possible damage to healthy cells. Chemotherapy for oesophageal cancer may be given alone or combined with radiotherapy.

For oesophageal cancer, chemotherapy is commonly given before surgery to shrink large tumours and destroy any cancer cells that may have spread. It may be used after surgery to reduce the chance of the disease coming back. Chemotherapy is also used on its own for people unable to have surgery.

Chemotherapy is usually given into a vein in your arm through a drip (intravenously). It may also be given through a tube called a port, catheter or vascular access device. You will usually receive treatment as an outpatient.

Most people receive a combination of drugs in repeating rounds of treatment for several months. These may be given on one day or continuously using a small pump that is linked to the tube implanted into the vein. There may be a rest period of a few weeks between each round. Your doctor will talk to you about how long your treatment will last.

Side effects of chemotherapy

The side effects of chemotherapy vary greatly, depending on the drugs you receive, how often you have treatment, and your general fitness and health. Side effects may include nausea and/ or vomiting, sore mouth or mouth ulcers, appetite changes and difficulty swallowing, skin and nail changes, numbness or tingling in the hands or feet, ringing in the ears, changed bowel habits (e.g. constipation, diarrhoea), and hair loss or thinning.

Chemotherapy reduces your white blood cell level, making it harder for your body to fight infections. If you feel unwell or have a temperature higher than 38°C, seek urgent medical attention.

Most side effects are temporary. Your treatment team can help you prevent or manage any side effects. See Understanding Chemotherapy for more information.

Palliative treatment

Palliative treatment aims to manage symptoms and improve people's quality of life without trying to cure the disease. It is best thought of as supportive care.

Many people think that palliative treatment is for people at the end of their life; however, it may be beneficial for people at any stage of advanced oesophageal cancer. It is about living for as long as possible in the most satisfying way you can.

Palliative treatment can help slow the spread of the cancer, and assist with managing symptoms such as pain, swallowing difficulty and nausea. For example, radiotherapy can help to relieve pain and make swallowing easier by helping to shrink a tumour blocking the oesophagus.

People with advanced oesophageal cancer who are having trouble swallowing food and fluids may have a flexible tube (stent) inserted into the oesophagus. The stent expands the oesophagus to allow fluid and food to pass into the stomach more easily. This stent also prevents food and saliva going into the lungs and causing infection. The stent does not treat the cancer but will allow you to eat and drink more normally. For more information about eating and swallowing, see managing side effects.

For more information see Understanding Palliative Care and Living with Advanced Cancer, or call Cancer Council 13 11 20.

Key points

  • The type of treatment you have for oesophageal cancer depends on where the cancer is located and how far it has spread.
  • Oesophageal cancer is usually treated with surgery to remove all or part of the oesophagus. This operation is called an oesophagectomy. The remaining parts of the digestive system are usually stitched together so that food can still be swallowed and digested.
  • Some small tumours may be removed using a long flexible tube (endoscopic resection) without removing the oesophagus.
  • Surgery will affect your eating and digestion. Learning to adapt to these changes will take time. A dietitian can help with your recovery.
  • People commonly have radiotherapy and/or chemotherapy before surgery. Radiotherapy and chemotherapy are also used as the main treatments if the cancer has spread.
  • Radiotherapy treatment uses x-rays to damage or kill cancer cells so they cannot multiply. It can cause side effects, such as oesophagitis, painful swallowing and difficulty eating.
  • Chemotherapy is the use of drugs to kill or slow the growth of cancer cells. The drugs can cause side effects, such as a sore mouth or appetite changes. Most side effects are temporary.
  • Palliative treatment seeks to improve quality of life by reducing the symptoms of advanced cancer without aiming to cure the disease.
  • A stent may be inserted into your oesophagus to allow you to eat and drink more normally.

Expert content reviewers:

Prof David Watson, Head, Flinders University Department of Surgery, Flinders Medical Centre, SA; Prof Bryan Burmeister, Senior Staff Specialist, Cancer Services, Princess Alexandra Hospital, QLD; Dr Fiona Day, Medical Oncologist, Calvary Mater Hospital, Newcastle, and Conjoint Senior Lecturer, University of Newcastle, NSW; Mark Diggle, Consumer; Merran Findlay, Executive Research Lead – Cancer Nutrition and Oncology Specialist Dietitian, Royal Prince Alfred Hospital, NSW; Rosie Newth, 13 11 20 Consultant, Cancer Council NSW; Dr David Ransom, Medical Oncologist, Fiona Stanley Hospital, WA; Megan Rogers, Specialist Nurse, Upper Gastrointestinal Cancer Service, Peter MacCallum Cancer Centre, VIC. We also thank the health professionals, consumers and editorial teams who have worked on previous editions of this title.

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