Chemotherapy for Esophageal Cancer: What Is Important To Know?

There are different chemotherapy options depending on the burden of disease, which refers to how sick someone is. There are different ways you can receive the medication: the most common are given through a needle into a vein (intravenous or IV chemotherapy). But sometimes it can also be taken as a pill, capsule, a liquid by mouth, or as an injection or shot.

Chemotherapy can be used in both adenocarcinoma and squamous cell carcinoma of the esophagus. Which drugs your doctors prescribe depends on the type of cancer you have and other factors.

“Chemotherapy is typically a drug that swims through your body, killing off cancer cells wherever they are, whether they are in your esophagus, in your great toe, in your hip, or your liver, or anywhere else. It’s a body-wide flush of cancer therapy,” Dr. Whit Burrows, a thoracic surgeon at University of Maryland Medical System, explains. “So, [it’s] very different from surgery, where we locally remove the cancer, or radiation therapy, when we don’t remove it, but we locally treat it.”

Types of esophageal cancer

There are 2 main types of esophageal cancer and there is little doubt that esophageal squamous cell carcinoma and adenocarcinomas represent two different diseases with distinct characteristics.

• Squamous cell carcinoma (SCC): This type of esophageal cancer starts in squamous cells that line the esophagus. It usually develops in the upper and middle part of the esophagus and smoking and alcohol are major risk factors. Worldwide, SCC is the most prevalente esophageal cancer subtype.
• Adenocarcinoma: This type begins in the glandular tissue in the lower part of the esophagus where the esophagus and the stomach come together. Barrett’s esophagus with intestinal metaplasia (a complication of gastroesophageal reflux disease), obesity, and smoking are the main risk factors for adenocarcinoma. The incidence of esophageal adenocarcinoma has increased dramatically in Western countries such that adenocarcinoma now accounts for > 60%of all esophageal cancers in the US.

Treating Esophageal Cancer

The treatment of esophageal cancer depends on the size and location of the tumor, the type of esophageal cancer, whether the cancer has spread, and the person's overall health. For cancer that has not spread beyond the esophagus and lymph nodes, doctors often recommend a combination of radiation therapy, chemotherapy, and surgery. The order of treatment varies, but chemotherapy and radiation therapy are commonly recommended before surgery or, for some people, instead of surgery.

“Sometimes, we have to deliver chemotherapy and radiation together prior to surgery,” Dr. Burrows explains, “And that it what we call the multimodality treatment of esophageal cancer.”

Treatment for esophageal cancer that has spread to other parts of the body usually involves radiation therapy and chemotherapy, which is sometimes combined with immunotherapy. Immunotherapy works by helping a patient's immune system to recognize and attack cancer, but it's not for everyone.

“It's important for a patient to be aware of immunotherapy as a treatment option. I highly encourage patients to ask their physicians about immunotherapy," Dr. Rutika Mehta, a medical oncologist at Moffitt Cancer Center in Tampa, FL, tells SurvivorNet.

How Chemotherapy works

Chemotherapy is a medication that travels through the bloodstream and reaches all parts of the body (it’s a systemic therapy). In general, they are powerful chemicals that treat cancer by attacking cells during specific parts of the cell replication (cell cycle). Cancer cells go through this process faster than normal cells, so chemotherapy has more of an effect on these fast-growing cells.

The goals for chemotherapy include:

• Shrink tumor size
• Lower the total number of cancer cells in your body
• Reduce the likelihood of cancer spreading
• Reduce current symptoms

Chemotherapy is administered in cycles, with a period of treatment followed by a period of rest to allow the body to recover from the treatment's side effects. The length and number of treatments, as well as the specific kind and dosage of medications used, will vary from patient to patient. Physicians have specific names for chemotherapy cycles, depending when they are given:

• Neoadjuvant therapy (or preoperative): Chemotherapy that is intended to shrink the tumor before surgery or radiation.
• Perioperative Chemotherapy: includes any chemotherapy around the time of surgery, e.g., preoperative, intraoperative, and immediately postoperative chemotherapy.
• Adjuvant therapy (or postoperative): Chemotherapy that attacks cancer cells after surgery or radiation.
• Curative therapy: Chemotherapy is the only treatment. It cures the cancer.
• Palliative or definitive therapy: Chemotherapy shrinks tumors and lessens symptoms, but does not cure the cancer.

Types of Chemotherapy

There are several kinds of chemotherapy drugs used for patients with esophageal cancer. In some instances, a combination of drugs is used. For esophageal cancer, you usually have a combination of 2 or 3 drugs. The most common drugs are:

• Fluorouracil (5FU) or capecitabine (Xeloda)
• Cisplatin, oxaliplatin or carboplatin
• Paclitaxel or docetaxel

Common combinations include:

• Cisplatin and capecitabine (CX)
• Cisplatin and fluorouracil (CF)
• Epirubicin, cisplatin and capecitabine (ECX)
• Epirubicin, cisplatin and fluorouracil (ECF)
• Carboplatin and paclitaxel
• Fluorouracil, oxalipatin and docetaxel (FLOT)

Preparing for Chemotherapy

It is likely that you will have tests before and during your chemotherapy course. These help your doctor decide whether you are fit enough for treatment and they can also compare the results with future tests to see how your treatment is working. Several tests may be performed, such as:

• A complete physical examination
• Blood tests
• X-rays
• Scans

One of the most important test is called a complete blood count (CBC): this is done to get the levels of blood cells produced by the bone marrow. Chemotherapy medication can stop your bone marrow producing enough red blood cells, white blood cells and platelets. So, before your treatment starts you need to have a blood test to check your levels of these. Depending on your results, your oncologist may recommend delaying chemotherapy or using specific treatments to improve your values before starting.

Understanding Chemotherapy Side Effects

Chemotherapy affects everyone differently, so there's no real definite side effects you can count on.

Below are some of the more common side effects that can affect patients during and after treatment. And while it's important to note that we've come a long with the management of these side effects, they can still have a great impact on people during their cancer battle.

Nausea

"One of the things that patients worry most about is nausea with chemotherapy," Dr. Michael Ulm, gynecologic oncologist at West Cancer Center, said during a previous interview with SurvivorNet. "Everybody remembers what their parents went through or what their aunts and uncles went through probably 15 or 20 years ago."

Even though people can still anticipate nausea, Dr. Ulm said your nausea shouldn't be as bad as you're imagining with today's arsenal of effective treatments to combat the side effect with medications you can even take at home.

"I tell my patients, with modern medicine and modern antiemetics that you should never have severe nausea and you should never throw up," Dr. Ulm said.

Hair Loss or Thinning

Many chemotherapies can cause hair loss or thinning.

Hair loss typically begins about three to four weeks after patients begin chemotherapy and continues throughout treatment. Patients can expect regrowth around four to six weeks after they complete treatment, but some patients may experience some changes to hair color and texture when it begins growing back.

The hair loss associated with chemotherapy is temporary, but this can be an incredibly distressing side effect for some. It's important to speak with your doctor about any personal issues that may be caused by treatment side effects, including the loss or thinning of your hair.

To help patients cope with hair loss, a doctor or nurse may be able to recommend a local wig-maker or other resources that can help slow down the process.

Fatigue

Fatigue is another possible symptom that has the potential to worsen as chemotherapy cycles add up. If chemotherapy left you with anemia, you can try treating that ease exhaustion. But rest breaks, frequent exercise and getting plenty of sleep at night can also help fight fatigue.

In an earlier interview, Dr. Zachary Reese, a medical oncologist at Intermountain Healthcare, spoke with SurvivorNet about what chemotherapy-related fatigue is like.

"What I typically tell patients is that (chemotherapy) is a bit of a roller coaster ride," he said. "You're going to feel tired about a week into treatment, and that's when you'll hit bottom. And then you'll start to come back up again just in time to do it all over. … You'll feel a little more tired the second time around than you did the first, and it will last a day longer."

Heart Problems

Cardiotoxicity, or problems in the heart and vascular (circulation) system, can be a side effect of chemotherapy.

While uncommon, cardiovascular disease is the second leading cause of death among breast cancer survivors behind only secondary malignancies due, in part, to the damage some cancer therapies can cause to the heart.

"From chemotherapy, high doses of anthracyclines, in particular, have been the prototype of cancer therapies that lead to cardiotoxicity," Dr. Emanuel Finet, a transplant cardiologist at Cleveland Clinic Cancer Center, previously told SurvivorNet.

Cancer patients at a high risk for heart problems can be older, younger with more aggressive chemotherapy, obese, smokers or dealing with pre-existing cardiovascular disease.

Blood-Forming Cell Damage

Chemotherapy drugs can damage all three types of blood-forming cells: red blood cells, platelets and white blood cells. This in turn can lead to various issues like anemia (low red blood cell count), thrombocytopenia (low blood platelet account) or neutropenia (low number of a type of white blood cell called neutrophil).

"One of the things that's changed in the coronavirus days is that now we're giving everybody this drug called Neupogen or Neulasta, and it helps boost your white (blood cell) count," Dr. Ulm recommended as a way to help your body fight infections.

Nerve Damage

Nerve damage, or neuropathy, can leave you with symptoms like "pins-and-needles," pain, burning, numbness, weakness or trouble detecting heat and cold.

These symptoms might worsen as chemotherapy treatments progress, but there are ways to combat them. Steroids, numbing patches or cream, antidepressant medicine, anti-seizure medication physical therapy, relaxation techniques, acupuncture or dosage adjustments may help with these symptoms.

And while the symptoms of nerve damage might go away once you finish treatment, there can be lasting effects that require ongoing treatments.

Questions to ask the health care team

• What type of esophageal cancer do I have?
• How will I receive chemotherapy treatments? Will I need a port?
• How often will I have chemotherapy? For how long?
• What are the risks and benefits of treatment with these drugs?
• Will my health insurance cover my treatment with this drug?
• What are the common side effects of the chemotherapy I will receive?

Learn more about SurvivorNet's rigorous medical review process.

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