Understanding Stage 4 Esophageal Cancer

About half of all Americans who have esophageal cancer are diagnosed at stage 4. At that point, the cancer is advanced and has spread to other areas of the body. For decades, this has meant limited treatment options and shorter survival. However, increasing knowledge about the disease and new treatment options have improved the outlook for many people with stage 4 esophageal cancer. 

“We have become more sophisticated in our understanding of how to identify patients who may benefit from newer kinds of therapy, and that has improved outcomes,” says Theodore Hong, MD, director of the Gastrointestinal Program in the Department of Radiation Oncology at Mass General Cancer Center. “Some patients can do incredibly well.”

Dr. Hong says an expert team can design an individualized treatment plan that may include chemotherapy, radiation, immunotherapy, and targeted therapy. “Our goals are to help folks live as long as possible and as well as possible. We really want to accomplish both of those goals,” he says.

Stages of esophageal cancer

A diagnosis of esophageal cancer should include the type of esophageal cancer and its stage, from 0 to 4:

• Stage 0 involves the presence of malignant cells in the esophagus, but the cells have not yet formed a tumor or invaded the esophageal lining. 
• Stage 1 marks the presence of a tumor that is only in the esophagus lining, not deep into the esophageal wall. 
• Stage 2 means the cancer is deeper into the muscle tissue and perhaps one or two nearby lymph nodes.
• Stage 3 indicates the cancer has spread into more tissues outside the esophagus, such as additional lymph nodes.
• Stage 4 involves invasion into distant lymph nodes and organs, such as the liver.

Your team also may include a letter in the stage (for example, Stage 2A or 3B). This provides even more detail about the size and extent of the cancer.

Can I be screened for esophageal cancer?

The United States does not have an established screening program for esophageal cancer; it is rather rare and affects far fewer Americans than other types of cancer. 

The only people who are screened for esophageal cancer are those who had longstanding GERD that developed into Barrett’s esophagus. People with Barrett’s esophagus are at increased risk for esophageal cancer, so they should have regular endoscopies to look for disease and catch it early.

“The disease is much more curable when found at an early stage,” Dr. Hong says. “However, the only patients who undergo screening are people who are in a Barrett’s surveillance program, and they’re the only patients in the United States who are found with early-stage disease.”

Treatment for stage 4 esophageal cancer

The team for stage 4 should be led by a medical oncologist and include radiation specialists, a surgeon in some cases, a nutritionist, a palliative care specialist to help with symptoms and goals of care, and a social worker to help you cope. They work together to provide a combination of treatments that are best for your individual disease and priorities. 

“Cancer care has become so highly specialized. It’s really important to see a team that has the experience to not just identify the best potential therapies that are available today, but also understand what options can be deployed to maximize the person’s experience and quality of life,” Dr. Hong says. 

The expert team will test the cancer to look for certain alterations that predict which therapies will be most effective in your specific case.

Surgery for stage 4 esophageal cancer

Surgery is not used often in stage 4 esophageal cancer. It is difficult to remove all of the cancer by the time it has spread. And surgery can delay the delivery of effective systemic treatments such as chemotherapy, immunotherapy, and targeted therapy.

“The best thing for a patient and the most important way to prolong a patient’s life is to provide an effective drug therapy that goes everywhere in the body. Esophageal surgery is a significant operation and has a risk of complications,” Dr. Hong explains.

Chemo for stage 4 esophageal cancer

Chemotherapy is one of the most important treatments for stage 4 esophageal cancer. Chemo travels throughout your body and kills cancer cells. There are many different types, and it is often combined with at least one other type of treatment. 

Radiation for advanced esophageal cancer

Radiation kills cancer cells and shrinks tumors. It is very effective in decreasing esophageal cancer stage 4 symptoms, specifically pain and trouble swallowing. Dr. Hong emphasizes that radiation can also control the disease for people who want or need a break from chemo. 

“It’s hard for patients to be on chemotherapy forever. At some point, we like to think about giving patients some time off chemotherapy so that they can enjoy a normal life without the accumulation of symptoms,” he says. “We are increasingly using radiation to control disease while people take a break from chemotherapy.”

Immunotherapy and targeted therapy for stage 4 esophageal cancer

Cancer cells can have certain characteristics or alterations that make them susceptible to additional new treatments. Special tests can identify these biomarkers and determine whether immunotherapy or targeted therapy will be effective for you.

Immunotherapy is a new type of therapy that helps your immune system recognize and attack cancer. Your team will test you for a protein called PDL1. They also will conduct microsatellite instability, or MSI, testing to look for another type of protein. If you have one of the proteins, then immunotherapy is likely to work. If the protein isn’t there, then immunotherapy will not be an option.

Another new treatment for stage 4 esophageal cancer is called targeted therapy. Some esophageal tumors have a protein that was initially described in breast cancer called HER2. If a test reveals that your tumor is HER2-positive, then a targeted therapy called trastuzumab can be added to your treatment plan. Targeted therapy targets molecules that cancer cells need to survive and grow.

Some patients will have several biomarkers at the same time, increasing the number of potentially effective treatments.