Dr Boffa on Factors Informing Early-Stage Esophageal Cancer Management

"One of the real key aspects of personalizing medicine is to truly take the time to understand goals of care. We've gotten so much better at understanding how tumors behave, making treatment easier and more effective. It's also important to get better at understanding what patients hope to get out of their treatment and what their priorities are."

Daniel Boffa, MD, professor of thoracic surgery, division chief of Thoracic Surgery, and the clinical director of the Center for Thoracic Cancers at Yale School of Medicine, discussed factors informing the choice between definitive surgery and chemoradiotherapy when determining the optimal treatment approach for patients with early-stage esophageal carcinoma.

For patients with early-stage esophageal cancer confined to the mucosa (T1a), endoscopic treatment has demonstrated high efficacy and is typically preferred due to its minimally invasive nature, Boffa stated. However, in cases where the tumor has invaded the submucosa (T1b), careful patient selection becomes critical, as the risk of lymph node involvement increases, he noted. Although endoscopic management may still be feasible at the earliest point of submucosal invasion, it involves a calculated trade-off, Boffa explained. For patients who are older, have comorbidities, or decline surgery, endoscopic therapy in the outpatient setting may remain an appropriate option despite the risk of underestimating disease extent, he added.

The ability to tailor treatment based on individual goals of care is central to modern oncology, Boffa commented. As the understanding of tumor biology has advanced and treatments have become more effective and less invasive, equal progress has been made in recognizing the importance of patient values and treatment priorities, he observed. Personalizing care means evaluating the clinical staging and integrating patients’ preferences into the decision-making process, Boffa stated.

For patients with more advanced disease involving lymph node metastases or deeper esophageal wall invasion, the current standard of care typically involves systemic therapy combined with surgery, he said. In cases where patients are not surgical candidates—either due to medical contraindications or personal choice—definitive chemoradiation offers a reasonable alternative, Boffa noted. This approach is particularly effective in esophageal squamous cell carcinoma, which tends to be more radiosensitive than adenocarcinoma, he added. Thus, while the histologic subtype and extent of disease inform treatment selection, patient-specific factors and preferences remain integral to individualized management strategies, Boffa concluded.