Treatment of Stage III Esophageal Cancer

This content has been reviewed and approved by

Chandra P. Belani, MD
Deputy Director, Penn State Cancer Institute
Miriam Beckner Professor of Medicine
Penn State University School of Medicine

Patients with stage III esophageal cancer have cancer that penetrates through the wall of the esophagus and spreads to the lymph nodes and/or nearby penetrated structures. This is a very common stage in patients with esophageal cancer. Physicians sometimes call stage III cancer “locally advanced.”

The following is a general overview of the treatment of stage III esophageal cancer. Circumstances unique to your situation and prognostic factors (factors that help your physician estimate your chance of recovery or the chance that your cancer will come back) may ultimately influence how your physician applies these general treatment principles to your situation. The information on this website is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.

Most new treatments come about through clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. Developing more effective cancer treatments requires cancer patients to help evaluate these new and innovative therapies.

Participating in a clinical trial may offer you access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. If you’re interested in participating in a clinical trial, you should discuss the risks and benefits of clinical trials with your physician. To ensure that you’re receiving the optimal treatment for your cancer, it’s important to stay informed and follow the cancer news to learn about new treatments and clinical trial results.

Types of Treatment

Optimal treatment of patients with stage III esophageal cancer often requires more than one therapeutic approach. It is therefore important to receive treatment at a medical center that can offer treatment that involves specialists in a variety of fields: medical oncologists, radiation oncologists, surgeons, medical gastroenterologists, and nutritionists.

For patients with stage III esophageal cancer, there are essentially two currently available treatment choices:

• Chemotherapy with or without radiation therapy before surgery
• Chemotherapy and radiation therapy without surgery

Surgery alone is not usually advised for patients with stage III esophageal cancer except as necessary to help with swallowing difficulties. There may be some exceptions to this recommendation for patients with stage III cancer who only have minimal lymph node involvement with cancer or for those with minimal spread of cancer to nearby structures.

The American Society of Radiology’s guidelines for treating esophageal cancer recommend chemotherapy and radiation therapy and no surgery for patients with stage III esophageal cancer. However, there are many current clinical trials directed at improving outcomes of patients with stage III esophageal cancer by administering chemotherapy and radiation therapy before surgery (neoadjuvant treatment).

This approach assumes that chemotherapy and radiation therapy will increase the likelihood that curative surgery is possible in patients who are inoperable at diagnosis. This approach also presumes that surgery can eliminate any residual cancer remaining after treatment with chemotherapy and radiation therapy. The major problem with this approach is the high death (mortality) rate following surgery.

To evaluate new chemotherapy regimens, clinical trials often include patients with stage III esophageal cancer with extensive local (nearby) and lymph node spread along with patients with metastatic stage IV esophageal cancer.

• Chemotherapy and radiation therapy as primary treatment - physicians usually combine chemotherapy with radiation therapy in treating patients with stage III esophageal cancer. Chemotherapy refers to anticancer drugs designed to treat cancer throughout the entire body (systemically). Chemotherapy and radiation therapy may act together to increase the destruction of cancer cells. Chemotherapy may also destroy cancer cells in locations radiation therapy does not reach.

• Neoadjuvant therapy - means receiving chemotherapy and/or radiation therapy administered before surgery. In theory, neoadjuvant therapy can decrease the size of the cancer, making it easier to remove with surgery.

Neoadjuvant therapy has several potential advantages: delivering immediate therapy to destroy any cancer cells that may spread outside of the esophagus, and reducing the size of the cancer, thereby making surgical removal (resection) easier. The role of neoadjuvant chemotherapy and radiation therapy before surgery in patients with localized esophageal cancer is controversial.

In some clinical studies, patients receiving neoadjuvant chemotherapy and radiation therapy experienced improved outcomes compared with surgery alone. Unfortunately, studies also report a higher death rate following surgery. This high death rate may cancel out any benefit of controlling cancer by this more intensive treatment approach. Clinical trials of new more effective and potentially less toxic chemotherapy regimens are ongoing because current results of treatment with or without surgery are unsatisfactory.

• Neoadjuvant and adjuvant therapy (treatment before surgery) - Researchers have also evaluated neoadjuvant low-dose chemotherapy before surgery followed by additional adjuvant chemotherapy after surgery.

Research is in progress to refine existing treatments and develop new ones. For information on some of the techniques currently under investigation, see Strategies to Improve Treatment.