The Role of Radiotherapy in Esophageal Cancer Treatment
- Radiation therapy uses high-energy rays (such as x-rays) to destroy cancer cells.
- Radiotherapy itself is painless, but some people may experience some general side effects (after 7 – 10 days) after treatment starts.
- It is often combined with other types of treatment, such as chemotherapy and/or surgery, to treat esophageal cancer.
- Chemotherapy can make radiation therapy more effective against some esophagus cancers. Using these 2 treatments together is called chemoradiation.
- In later stage esophageal cancer (stages 2-3), it’s common for patients to receive trimodality therapy, a combination of chemotherapy, radiation, and surgery.
It is often combined with other types of treatment, such as chemotherapy and/or surgery, to treat esophageal cancer. Chemotherapy can make radiation therapy more effective against some esophagus cancers. Using these two treatments together is called chemoradiation.Read More
Types of radiation therapy
There are two main ways to deliver radiotherapy including external beam radiation, where the radiation comes from outside of the body, and internal radiation called brachytherapy, where radioactive seeds are placed directly into a tumor. Both external beam radiotherapy and brachytherapy are used to treat esophageal cancer, and both have pros and cons. The external form of radiation is used more frequently for esophageal cancer. You should have a discussion with your doctor on which treatment is best for you.
Radiation therapy alone is not usually recommended for primary treatment of esophageal cancer because radiation administered in combination with chemotherapy improves survival compared to treatment with radiation alone. In general, current evidence suggests that combined chemotherapy and radiation therapy is superior to either therapy alone as primary therapy for esophageal cancer.
External-beam radiation therapy (EBRT)
This type of radiotherapy is used most often for people with esophageal cancer. The radiation is focused on the cancer from a machine outside the body. It is much like getting an x-ray, but the radiation is more intense. How often and how long the radiation treatments are delivered depends on the reason the radiation is being given and other factors. It can last anywhere from a few days to weeks.
There are new forms of radiation therapy that use highly sophisticated technology to deliver radiation to cancer cells while sparing surrounding normal tissue and reducing side effects, such as:
- Three-dimensional conformal radiation therapy (3D-CRT): This procedure uses a computer to create a 3-dimensional picture of the tumor. This allows doctors to give the highest possible dose of radiation to the tumor, while sparing the normal tissue as much as possible. Also called 3-dimensional conformal radiation therapy and 3-dimensional radiation therapy.
- Intensity-modulated radiation therapy (IMRT): This consists of using advanced technology to manipulate photon and proton beams of radiation to conform to the shape of a tumor. It uses multiple small photon or proton beams of varying intensities to precisely irradiate a tumor. The goal of IMRT is to conform the radiation dose to the target and to avoid or reduce exposure of healthy tissue to limit the side effects of treatment.
Internal radiation therapy (brachytherapy)
With this type of radiation, the doctor passes an endoscope (a long, flexible tube) down the throat to place radioactive material very close to the cancer. The radiation travels only a short distance, so it reaches the tumor but has little effect on nearby normal tissues. This usually means fewer side effects than with external beam radiation. The radioactive source is removed a short time later.
When can radiation therapy be used for esophageal cancer?
“What determines whether you can get that combination of chemotherapy and radiation depends on your symptoms. Symptoms really dictate whether or not you’re going to get radiation there, but also, do you have distant disease? If you have a tumor in the middle of the chest but a metastasis [somewhere else], if you don’t need radiation to open things up so you can swallow, usually in those cases they will just give you chemotherapy.” Dr. Raja Flores, a thoracic surgeon with Mount Sinai Health System, told SurvivorNet.
Dr. Flores noted that if you have a tumor that is considered a T1 legion (a small tumor that is on the inner surface of the esophagus (esophageal mucosa), it can sometimes be removed with an endoscope (small surgery).
“When it gets a little more advanced, T2, T3, where it goes through the thickness of the wall of the esophagus, that frequently requires chemotherapy and radiation, followed by surgery,” Dr. Flores added. This is called Tri-Modality Therapy (combination of chemotherapy, radiation, and surgery). It is most common for chemotherapy and radiation to take place before surgery.
When a patient comes in with a large “obstruction,” which cannot be removed with just surgery, Dr. Flores said the first move may be to send this patient to the radiation oncologist to get treatment started. “The majority of the times, you’ll get a response, things will open up, you will be able to eat,” Dr. Flores said.
To summarize, radiation therapy may be used:
- Before surgery (and along with chemo when possible), to try to shrink the cancer and make it easier to remove. This is called neoadjuvant treatment. A very important study was published on the International Journal of Cancer: it was proved that neoadjuvant chemoradiotherapy improved overall survival when compared to all other treatments including surgery alone, neoadjuvant chemotherapy and neoadjuvant radiotherapy.
- After surgery (and along with chemo when possible), to try to kill any cancer cells that may have been left behind but are too small to see. This is known as adjuvant therapy.
- To decrease the symptoms of advanced esophageal cancer such as pain, bleeding, or trouble swallowing. This is called palliative therapy
- As part of the main treatment of esophageal cancer in some patients, typically along with chemo (chemoradiation). This is often used for people who can’t have surgery due to poor health or for people who don’t want surgery. This is called definitive chemoradiotherapy.
Radiotherapy itself is painless, but some people may experience some general side effects as soon as seven to 10 days after treatment starts. According to the American Cancer Society, these include fatigue, nausea and vomiting, appetite loss, blistering or peeling skin, and hair loss in the area where radiation enters the body. These side effects can be severe if the radiation is given along with chemotherapy, but they usually go away after the treatment ends.
Melissa Culligan, a thoracic surgery nurse at the University of Maryland Medical Center, says it’s important that you stay in close touch with the members of your cancer care team and notify them of any discomfort so that they can help manage these issues.
Questions to Ask Your Doctor
- Will I need radiation for my esophageal cancer?
- What type of radiation will I receive?
- Is it better if I receive radiation through the new forms of radiation delivery, such as IMRT or 3D-CRT?
- How long will the sessions take?
- How many treatments will I need?
- How flexible is the radiation schedule?
- Can I work while receiving radiation?
- What type of side effects may I experience?