Palliative therapies in esophageal cancer
Esophageal cancer is a lethal malignancy, with a rising incidence worldwide, but still a rare disease in Norway (0,7 % of all newly diagnosed cancers in Norway). Most of the patients presents with advanced disease, meaning that they can not be operated, and will at some point require palliation. The mortality rates have improved over the last decades, but remains low (only 10 % overall 5 years survival in Europe).
Palliation is often required for symptoms, such as dysphagia, gastrointestinal bleeding, aspiration caused by tracheoesophageal fistula, nausea and emesis secondary to gastric outlet obstruction, and malnutrition. The main goal of most treatment is to maintain oral food intake, in order to stabilize or improve the patient s nutritional status, as well as quality of life.
The different treatment options include chemotherapy, radiation (external and brachytherapy), photo dynamic treatment, laser therapy and the most widely used; insertion of stents.
External radiotherapy shows effect on palliation of dysphagia in most patients, but no improvement on survival. Complication rates around 10-40 %, where esophagitis is most common. Brachytherapy shows efficacy in doses between 16-18 Gy, complication rates are low and this treatment has the advantage of shorter treatment intervals than external and chemotherapy. Laser and PDT treatment shows effect in relieving dysphagia, but this demands small tumours and specific selection of patients, and are currently being used less due to high rate of recurrent dysphagia and longlasting side effects. Chemotherapy has in the studies we ve found showed treatment effect in 65 %, which is by far higher than older studies, but the treatment demands healthy patients and is time-consuming. Stent insertion in the esophagus is expensive, but the treatment is effective, can be made as an outpatient procedure and has few side effects.
It still remains to find the best treatment options for this group of patients, but judging from our experience - the way to proceed is multimodal with stent insertion at an earlier time and later chemotherapy and brachytherapy or external radiation.