Are There New Developments for Treating Esophageal Cancer?
- Over the past decade, rates of esophageal cancer have been increasing slightly.
- Unfortunately, the disease can be difficult to treat because it is often diagnosed at later stages.
- It’s important to be aware of symptoms, such as pain/difficulty swallowing, weight loss, pain behind the breastbone, and hoarseness and/or a cough.
- In recent years, there have been some promising developments in treating advanced esophageal cancer, including the approval or checkpoint inhibitors Opdivo and Yervoy.
One reason for the increase could be that the disease can be difficult to detect. So why is that and are there any new treatment options to offer hope to patients?
Diagnosing Esophageal Cancer
Read More"It's one of the cancers with some of the lowest cure rates out there. But like many cancers, if we find it early, we can often treat it effectively either with surgery, with surgery and chemotherapy, or with chemotherapy and radiation.”
Dr. Stiles says esophageal cancer may be diagnosed at later stages because symptoms of the disease can be tough “to pin down sometimes” so those experiencing them may not think of cancer right away.
It's important to be aware of signs of this disease, which include:
- Pain/difficulty swallowing
- Weight loss
- Pain behind the breastbone
- Hoarseness/cough
- Indigestion/heartburn
- A lump under the skin
This is why it’s so important to speak to your doctor about getting checked out if you do have concerning symptoms or notice any changes to your body or health. The earlier you are diagnosed, the better the prognosis will be.
Diagnosing esophageal cancer may involve taking a physical exam and health history, a chest X-ray, and an upper endoscopy (where the walls of the esophagus are examined using a small camera).
Other tests may be used as well to help get an accurate diagnosis. The upper endoscopy is particularly important because it helps your doctor to clearly see if there are any abnormalities in the wall of your esophagus.
Treating Esophageal Cancer
The treatment route you and your medical team decide on after an esophageal cancer diagnosis will depend on several factors, including the severity of the disease and your overall health.
Often, the treatment approach will involve several different types of therapy, Dr. Stiles explained.
Currently, there are several treatment options available for people with esophageal cancer. These include:
- Surgery
- Radiation
- Chemotherapy
- Chemo-radiation
- Laser therapy
- Electroagulation (using heat from an electric current to destroy abnormal tissue)
- Immunotherapy (training the immune system to recognize and attack cancer cells)
"It's rare these days that I just do surgery for a patient with esophageal cancer. They've often gotten other treatments," Dr. Stiles said.
"Remarkably, with very early stage disease, stage one, a patient can often have their tumor resected endoscopically, through a scope down their esophagus without the need to invasive surgery,” Stiles added. However, it’s important to know that that’s “a very selected group of very early, invasive cancer.”
So what’s available for patients with advanced disease?
"Because esophageal cancer is such an insidious disease, and because it has high rates of recurrence and metastasis (spreading), we really try to throw everything we have at it," Dr. Stiles said.
"For patients with more advanced disease that are not surgically resectable (removable), they can often also be treated with chemotherapy, sometimes with radiation with what's called local control, to try to shrink the tumor so that patient can eat better.”
He added that some patients may also benefit from newer options like immunotherapy and targeted therapy, which specifically targets proteins that control cancer cell growth, according to the National Cancer Institute.
Treating Esophageal Cancer With Immunotherapy
Immunotherapy is among the most-watched areas of medicine and is a relatively new type of cancer treatment. It harnesses the power of the immune system to recognize and kill cancer cells. In some patients, the results can be life-changing.
It's already proved enormously effective in treating several cancers, but it doesn't work for everyone.
Dr. Steven Rosenberg, Chief of Surgery at the National Cancer Institute, is a pioneer in immunotherapy research and treatment.
"Using a patient's own immune cells is a very complex way to treat a cancer," says Dr. Rosenberg. His team has developed methods for genetically modifying a patient's own immune cells "to recognize the cancer in a new way" and to kill it.
Thankfully, the government has approved new immunotherapy drugs to treat esophageal cancer, bringing hope to patients with advanced disease.
Dr. Brendon Stiles explains when immunotherapy can be used for esophageal cancer.
These immunotherapy drugs are known as checkpoint inhibitors. They target proteins found on immune or cancer cells (such as PD-1, PD-L1, or HER2) and prevent them from binding together. These drugs don’t kill cancer cells directly but stimulate the immune system to find these cells and attack them while (ideally) not going after nearby healthy cells.
The following drugs are approved in the treatment of advanced esophageal cancer, and those who have specific types of the disease may have improved survival rates.
Keytruda (generic name pembrolizumab)
- Approved for patients with esophageal squamous cell carcinoma (ESCC) with high levels of PD-L1 as a second-line treatment (treatment after initial therapy).
- It can also be used as a first treatment (in combination with chemotherapy) for incurable, locally advanced (meaning it has spread into nearby tissues) or metastatic (meaning it has spread to distant organs) esophageal and gastroesophageal junction (GEJ) adenocarcinoma and squamous cell carcinoma no matter the PD-L1 expression.
- Patients with HER2-positive incurable locally advanced metastatic esophageal and GEJ adenocarcinoma may also be given Keytruda in combination with chemotherapy and trastuzumab (a type of drug known as a monoclonal antibody) as a first treatment no matter the PD-L1 expression.
Opdivo (generic name nivolumab)
- This checkpoint inhibitor targets the PD-1/PD-L1 pathway and can be used even if patients do not express high levels of PD-L1 (though some research suggests it may benefit those with high PD-L1 expression more).
- It can be used as a first-line treatment (in combination with chemotherapy) for esophageal or GEJ adenocarcinoma regardless of PD-L1 expression, and as a second-line treatment for ESCC regardless of PD-L1 expression.
- Sometimes, it is given after surgery, chemotherapy, and radiation in esophageal and gastroesophageal adenocarcinoma and squamous cell carcinoma if doctors suspect cancer cells are still lingering in tissue after surgery.
Yervoy ( generic name ipilimumab)
- Approved for treatment in combination with either chemotherapy or Opdivo for patients with advanced ESCC regardless of the PD-L1 expression.
- Doctors may suggest people with PD-L1 positive ESCC consider Opdivo and Yervoy together. The recommendation will depend on how much PD-L1 is expressed.
Opdivo and Yervoy were approved just in 2022 by the Food and Drug Administration. Both showed some promise in extending survival for patients with advanced esophageal cancer.
Is Immunotherapy Right for Me?
To determine if a patient is a candidate for immunotherapy, the following steps may happen:
- Your doctor will likely test your tumor's PDL-1 level when you have a biopsy.
- The results of a PDL-1 test are sometimes reported as a score, which represents the percentage of cancer cells that test positive for PDL-1.
- The higher your score, the more likely that immunotherapy is a good treatment approach for you.
- If your tumor has a high PDL-1 level, you may be able to get pembrolizumab plus chemotherapy.
But what’s good to know is that Opdivo and Yervoy are both available for patients regardless of how high their PDL-1 level is. So it’s important to ask your doctor if those therapies make sense for you.
Dr. Stiles stressed the importance of patients advocating for themselves and asking any questions they may have about treatment options.
“Patients should never be afraid to push doctors and say, 'What are the treatment options at my stage? Do I need multi-modality therapy?' That means therapy with more than just surgery or more than just radiation with chemotherapy,” Dr. Stiles said.
Immunotherapy Side Effects
Like all cancer treatments, immunotherapy can cause uncomfortable side effects. Dr. Mohana Roy, clinical assistant professor at Stanford University School of Medicine, told SurvivorNet that most of her patients tolerate immunotherapy very well, but about 10% experience issues.
Common side effects include:
- Fatigue
- Rashes
- Diarrhea
- Weakness
- Headache
- Impaired thyroid function
A concern with revving up the body’s immune system is that it could trigger significant inflammation. The body could start attacking its own organs, which can lead to serious and permanent issues.
With immunotherapy, it’s critical to inform your doctor about any side effects you may be experiencing.
"You do not know who it will affect and who it will not," Dr. Roy said. "When I start someone on immunotherapy, I say, 'Anything weird, I need to know about it.'"
Questions to Ask Your Doctor About Immunotherapy for Esophageal Cancer
- How aggressively should we treat my cancer?
- Am I eligible to receive immunotherapy? Am I more, or less, likely to respond to this treatment?
- What is my tumor's PDL-1 level?
- If my tumor's PDL-1 level is ≥ 1%, will it change the course of my treatment?
- What are the most common side effects of immunotherapy and how can I manage them?
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