ASCO Clinical Practice Guidelines for Clinician Management of Patients with Advanced Esophageal Cancer

Web Exclusives —October 25, 2021

Esophageal cancer causes an estimated 450,000 deaths globally each year. In East Asia and the Middle East, squamous-cell carcinoma (SCC) is the most common type of esophageal cancer, while in Western countries, adenocarcinoma is more common. Locally advanced esophageal cancer tumors are found in local structures, and may involve regional lymph nodes, but it is not found in metastatic sites. Esophagectomy has been the main treatment for this type of cancer, but this surgery has a poor prognosis. Research for additional therapies to treat locally advanced esophageal cancer is ongoing and includes chemotherapy and radiation therapy. The American Society of Clinical Oncology convened an expert panel to conduct a recent literature review and to develop an evidence-based clinical practice guideline to assist clinicians in making appropriate management decisions for their patients with locally advanced esophageal cancer and resectable Siewert I/II gastroesophageal junction adenocarcinoma. The panel evaluated 17 randomized control trials to develop recommendations for specific esophageal cancer subtypes. When reviewing the literature and developing the recommendations, the expert panel addressed clinical questions that incorporated considerations for neoadjuvant or adjuvant therapy with or without surgery in light of the 2 esophageal cancer types.

The panel strongly recommended multimodality therapy for patients with locally advanced esophageal adenocarcinoma, but in patients with low-risk, well-differentiated lesions, surgery may be more appropriate. For patients with locally advanced esophageal adenocarcinoma, preoperative chemoradiotherapy (CRT) or perioperative chemotherapy is strongly recommended. Since CRT may contribute to more severe postoperative complications than chemotherapy, patients should be evaluated with this possibility in mind. Radiation therapy may be beneficial if less extensive surgery is necessary or if there are inadequate margins found after surgery. Patients who are unable to take radiation or postoperative chemotherapy should be considered for preoperative chemotherapy. CRT is recommended for patients who are unable to undergo surgery.

The expert panel strongly recommends that patients with locally advanced esophageal SCC should be offered preoperative CRT or CRT without surgery. Patients who have a complete response to CRT may be considered for a salvage esophagectomy based on evidence from an ongoing clinical trial. If the patient is unable to take radiation therapy, preoperative chemotherapy can be considered. If the patient has cervical esophageal tumors, definitive CRT is recommended. Recurrent or persistent tumors in the cervical esophagus should trigger consideration for surgery. Surgery considerations for patients with locally advanced esophageal SCC should include patient age, comorbidities and preference, and caregiver support.

The panel encourages optimal patient–clinician communication when discussing the treatment recommendations and shared decision-making when deciding on treatment for locally advanced esophageal cancer.


Shah MA, Kennedy EB, Catenacci DV, et al. Treatment of locally advanced esophageal carcinoma: ASCO guideline [published correction appears in J Clin Oncol. 2020;38:3976]. J Clin Oncol. 2020;38:2677-2694.

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Last modified: October 28, 2021

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