Esophageal Cancer: Should Chemotherapy Come Before Surgery?

When it comes to treating esophageal cancer, the first step after a clear diagnosis is to determine the clinical stage of the disease. In early-stage esophageal cancer, particularly when the tumor is confined to the mucosa, neither surgery nor chemotherapy is typically required. Instead, a minimally invasive procedure such as endoscopic mucosal resection or endoscopic submucosal dissection can be highly effective.

However, in most clinical scenarios, approximately 90% of diagnosed cases are identified at a locally advanced or middle-to-late stage. Historically, the approach for these patients was to proceed with surgery as soon as possible, provided their physical condition allowed it. Over the past decade, however, research has shown that neoadjuvant therapy—chemotherapy or chemoradiation before surgery—can significantly reduce tumor size and stage, thereby improving the chances of complete surgical removal and long-term survival.

Studies have demonstrated that preoperative chemotherapy can lead to better outcomes and extended survival, especially for patients with locally advanced esophageal cancer. Moreover, recent findings suggest that even patients with mid-stage cancer can benefit from neoadjuvant chemotherapy before undergoing surgery.

In countries like China, where esophageal squamous cell carcinoma is particularly common, neoadjuvant chemotherapy has shown strong effectiveness. For this reason, current guidelines often recommend a neoadjuvant approach—chemotherapy followed by surgery—for patients with locally advanced or middle-to-late stage esophageal cancer.

This shift in treatment strategy reflects the growing understanding of how multimodal therapies can improve patient outcomes. As research continues to evolve, personalized treatment plans combining chemotherapy, radiation, and surgery are becoming the standard of care in managing esophageal cancer effectively.