The treatment of esophageal cancer requires a multidisciplinary approach that includes surgery, internal medicine, radiotherapy, endoscopy, and interventional medicine. However, for patients with “resectable” esophageal cancer, surgery is the most important and central treatment and the only possible way to achieve a curative outcome. The surgeon plays a leading role in the development of the overall treatment strategy.
The place of surgery in the management of esophageal cancer
Comprehensive global guidelines suggest that surgery is the treatment of choice for early-stage esophageal cancer; progressive esophageal cancer can be treated with radiation or chemotherapy (neoadjuvant therapy) before surgery to allow the lesion to shrink, and then surgery can be an option for patients with advanced disease, if necessary, with palliative resection.
In 2018, the latest 2nd edition of the National Comprehensive Cancer Network s (NCCN) guidelines clearly state that radical esophageal cancer surgery should be performed for early-stage, non-cervical segmental esophageal cancer as long as the physical condition meets the criteria.
In its latest 2016 guidelines, the European Society for Clinical Oncology (ESMO) states that patients with early-stage esophageal cancer should undergo surgery; preoperative neoadjuvant chemotherapy + surgery is recommended for progressive adenocarcinoma; preoperative neoadjuvant radiotherapy + surgery is recommended for progressive squamous carcinoma; and patients with advanced stage, or If the lesion is located too high to be operated, radical radiotherapy is usually performed, and palliative esophagectomy is also recommended if necessary.
In its guidelines, the Society of Thoracic Surgeons (STS) recommends surgery after neoadjuvant chemotherapy for patients with esophageal cancer at the highest recommendation level.
The Japanese guidelines for esophageal cancer recommend that all patients who meet the indications should undergo resection, and patients with cervical esophageal cancer also need to undergo laryngectomy.
The guidelines published in Taiwan, China, also confirm the importance of surgery in the treatment of esophageal cancer and recommend preoperative nutritional support therapy.
What are the results of esophageal cancer surgery?
The benefit of surgery is very clear
As long as the indications for surgery are met, then patients who undergo surgery have far better outcomes than those who do not.
From 2004 to 2014 18,459 patients with esophageal cancer were included in the American Cancer Center database, 708 of whom had indications for surgery but declined surgery in favor of chemotherapy, radiation therapy, or combination radiotherapy.
At the same time, scientists identified 538 patients with similar medical conditions and disease who were willing to undergo surgery. The comparison showed that those who refused surgery had a median survival time of 21 months, while those who had surgery had a much better figure of 32 months. The benefit of surgery is clear.
Surgery is not “perfect”
Data suggest that the perioperative mortality rate (i.e., before, during, and after surgery) for patients with surgically treated esophageal cancer is about 3.1%; also, 33.1% of patients who have surgery may have at least one complication.
However, there is a lack of large-sample, high-quality, randomized, prospective, multicenter evidence regarding surgical mortality, complication rates, and long-term survival. This is because the difficulty of esophageal cancer surgery makes physician-to-physician and hospital-to-hospital comparisons difficult. In addition, operator experience and postoperative management of patients are important factors that influence postoperative complications and mortality.
I hope you understand that surgery is important, but it is not the whole story of esophageal cancer treatment.
Your doctor also needs to refine your preoperative evaluation, perform the necessary preoperative neoadjuvant therapy, supportive therapy during surgery, and postoperative adjuvant therapy and follow-up. All of this requires a joint effort between the doctor and patient to give you a better quality of life and a longer survival time.