A practical guide to the management of dysphagia in patients with metastatic esophageal cancer

In patients with esophageal cancer, dysphagia can be a distressing symptom, subsequently resulting in weight loss and malnutrition. While luminal obstruction is a common complication, the optimal management approach remains undefined. Given the high morbidity and mortality of esophagectomy and esophageal bypass, surgical palliation has long fallen out of favor. Instead, various other palliative approaches are available, all of which are relatively effective, but differ in regards to time to benefit, durability and toxicity. The available literature is relatively limited, and decisions regarding how to manage dysphagia, and when to appropriately employ these various therapies, are left to individual judgment. Using a tertiary center experience and a review of the current literature, we would typically recommend either systemic chemotherapy or palliative external beam radiotherapy (EBRT) as initial measures. The benefits of chemotherapy include the high likelihood of symptomatic improvement, avoidance of delays in systemic therapy, and minimal loco-regional toxicity. Radiotherapy would similarly be an effective initial approach and may be best suited for patients with low volume (oligo-metastatic) disease. For patients who develop progressive dysphagia later in their disease course, radiotherapy or SEMS placement are the main therapy options. We recommend against “double palliation,” in which patients receive two palliative therapies simultaneously. Overall, decisions regarding management of malignant dysphagia should be individualized to consider the severity of the obstruction, the need for systemic therapy, prior therapy received, and finally the patient’s life expectancy and personal wishes.