Can I have an esophageal cancer resection?

by Specialist

When esophageal cancer is detected, can it be treated surgically? From a professional perspective, doctors need to do two things:

  • Is the tumor suitable for surgical removal?

  • Can the patient’s physical condition tolerate the surgery?
  • Can the patient physically tolerate the surgery?

Physical condition

Esophageal cancer surgery is a major surgical procedure that is relatively invasive, so there are certain requirements for your physical condition. The attending surgeon will conduct a detailed preoperative consultation and physical examination to understand your general condition, past medical history, and nutritional status.

If you have poor mental status, anemia, heart disease, pulmonary dysfunction, immune dysfunction, liver disease, renal impairment, abnormal thyroid function, electrolyte abnormalities, etc., the surgeon will help you adjust your mental status and assess the function of major organs, etc., before making a surgical plan. Before surgery, you will also need a consultation with an internist to bring your blood pressure, lipids, and blood sugar to normal levels and to control chronic conditions such as chronic obstructive pulmonary disease (COPD) before you can have surgery.

Clearly unsuitable for surgery are:

  1. A history of heart attack or brain attack within 6 months;

  2. coagulation dysfunction;

  3. Vital organ dysfunction (e.g., cardiac failure, respiratory failure, renal failure, etc.).

So, how does your doctor assess your medical condition? First, the surgeon and anesthesiologist will make an initial determination using two scoring systems.

Surgeons commonly use the ECOG PS score

This scoring system, developed by the Eastern Cooperative Oncology Group (ECOG), assesses your performance status (PS).

If you have a score of 0 or 1, you are considered to be able to tolerate surgery or chemotherapy.

The ECOG scores are as follows:

  • Grade 0: completely normal mobility, no difference from before the onset of disease;

  • Grade 1: Ability to walk freely and perform light physical activities, including general household or office work, but not heavier physical activities;
  • Grade 2: Ability to walk freely and perform light physical activities, including general household or office work, but not heavier physical activities;

  • Level 2: able to walk freely and live on their own, but have lost the ability to work, and can get up and move around at least half the time during the day;

  • Grade 3: only partially able to take care of themselves, bedridden or wheelchair-bound for more than half of the day;

  • Grade 4: bedridden and unable to care for himself/herself;

  • Grade 5: Death.

Common ASA score for anesthesiologists

This score is suggested by the American Society of Anesthesiologists (ASA) and allows you to assess anesthesia risk by grading your general health status.

The ASA assessment is as follows:

  • Grades I-II, good tolerance for anesthesia and surgery, less risky;

  • Grade III, your organ function is within the compensatory range but your tolerance for anesthesia and surgery is diminished and risky, but you can tolerate anesthesia if you prepare adequately before surgery;

  • Grade IV, where the risk of anesthesia and surgery is high due to inadequate organ function, and perioperative mortality is high even with adequate preoperative preparation;
  • Grade V, where the risk of anesthesia and surgery is high due to inadequate organ function.
  • Grade V, generally a dying patient with high risk of anesthesia and surgery, is not suitable for surgery.

See below for details:

ASA Disease Classification and Perioperative Mortality

Grading

I

III

IV

Standard Mortality (%)
Physically healthy, well developed, well nourished, normal function of organs 0.06~0.08
II Mild coexisting disease in addition to surgical disease, functional metabolic soundness 0.27 to 0.40
Severe coexisting disease with limited physical activity but still able to manage daily activities 1.82 to 4.30
Severe coexisting disorders, loss of ability to perform daily activities, and frequent life-threatening conditions 7.80 to 23.0
V Dying patients who have difficulty staying alive for 24 hours, regardless of surgery 9.40 to 50.7
VI diagnosed as brain dead, whose organs are intended for organ transplantation –

In addition to these two scoring criteria, your doctor will refer to other test results, such as liver and kidney function and cardiopulmonary function, for a systematic and comprehensive assessment.

Tumor status

The doctor will need to evaluate the clinical stage of the tumor and determine whether you can have surgery through upper gastrointestinal imaging, gastroscopy, pathology biopsy, enhanced CT of the chest and/or abdomen, ultrasound gastroscopy, and whole-body PET-CT.

How is esophageal cancer staged?

The National Comprehensive Cancer Network guidelines (NCCN) make the following treatment recommendations:

  • Patients with early stage (roughly including clinical stage I and II without lymph node metastasis) can be treated directly with surgery;

  • Patients with intermediate or locally advanced disease (including roughly clinical stages III and IV) require preoperative neoadjuvant chemotherapy followed by surgery.

The chart below tells us that early-stage esophageal cancer, resectable intermediate-stage esophageal cancer, and partially resectable locally advanced esophageal cancer after neoadjuvant therapy are all indications for surgery.

Patients with existing distant metastases (staged as M1) and tumors that cannot be resected radically (R0 resection, i.e., complete, tumor-free resection) are not candidates for surgery.

What you should know is that if your doctor decides that you are a candidate for surgery, you should seek further treatment under your doctor’s guidance, and if your doctor decides that you are lost to surgery, you should understand and continue to follow a treatment plan that is more appropriate for you.