Esophageal Cancer Medication

Updated: Jun 20, 2017
  • Author: Muhammad Masab, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Medication

Medication Summary

Most of the chemotherapy regimens currently used for the treatment of esophageal cancer, including alkylating, antimetabolite, anthracycline, and antimicrotubular agents, have not been approved by the US Food and Drug Administration (FDA). Following are the recommended regimens for the treatment of esophageal cancer. These are based on extrapolations from the published literature and clinical practice. 

For preoperative chemoradiation, preferred regimens (category 1) are as follows:

  • Paclitaxel and carboplatin
  • Fluorouracil and cisplatin
  • Fluorouracil and oxaliplatin

Other preoperative chemoradiation regimens (category 2B) are as follows:

  • Irinotecan and cisplatin
  • Paclitaxel and fluoropyrimidine (fluorouracil or capecitabine)

For definitive chemoradiation, preferred regimens are as follows:

  • Fluorouracil and cisplatin (category 1)
  • Fluorouracil and oxaliplatin (category 1)
  • Paclitaxel and carboplatin

Other definitive chemoradiation regimens are as follows:

  • Cisplatin with docetaxel or paclitaxel
  • Irinotecan and cisplatin (category 2B)
  • Paclitaxel and fluoropyrimidine (fluorouracil or capecitabine) (category 2B)

Perioperative chemotherapy is used only for adenocarcinoma of the thoracic esophagus. Three preoperative cycles and posteroperative  cycles of the following may be given:

  • Fluorouracil and cisplatin (category 1)
  • Fluoropyrimidine and oxaliplatin
  • ECF (epirubicin, cisplatin, fluorouracil) (category 2B)

Preoperative chemotherapy is used only for adenocarcinoma of the thoracic esophagus. A total of two cycles of fluorouracil and cisplatin (category 2B) is given.

With postoperative chemoradiation, fluoropyrimidine (infusional fluorouracil or capecitabine) is given before and after fluoropyrimidine-based chemoradiation.

For postoperative chemotherapy, capecitabine plus oxaliplatin is used.

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Antineoplastics, Antimetabolite

Class Summary

These agents inhibit cell growth and proliferation. They interfere with DNA synthesis by blocking the methylation of deoxyuridylic acid.

Fluorouracil (Adrucil)

Fluorouracil is a pyrimidine antimetabolite. Several mechanisms of action have been proposed, including inhibition of thymidylate synthase and inhibition of RNA synthesis. This agent is also a potent radiosensitizer.

Capecitabine (Xeloda)

Capecitabine is a pyrimidine antimetabolite and a prodrug of fluorouracil. It forms the active moiety, fluorouracil, by undergoing hydrolysis in the liver and tissues. Capecitabine is used for the treatment of esophageal cancer, which is an off-label indication.

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Antineoplastics, Alkylating

Class Summary

These agents inhibit cell growth and proliferation, interfering with DNA synthesis by the formation of DNA cross-links. Alkylating agents can have serious adverse effects such as bone marrow suppression, anaphylactic-like reactions, ototoxicity, renal toxicity, and vomiting.

Cisplatin

Intrastrand cross-linking of DNA and inhibition of DNA precursors are among the proposed mechanisms of action for cisplatin. This agent is used in combination with radiation therapy. Cisplatin has black box warnings for adverse reactions, including anaphylactic-like reactions, ototoxicity, and renal toxicity.

Carboplatin

Carboplatin is a platinum alkylating agent that interferes with the function of DNA by producing interstrand DNA cross-links. It can be used in combination with paclitaxel for the treatment of esophageal cancer, which is an off-label indication. Carboplatin has black box warnings including bone marrow suppression, anaphylactic reactions, and vomiting.

Oxaliplatin (Eloxatin)

Oxaliplatin is a platinum alkylating agent that inhibits DNA replication and transcription, resulting in cell death. It can be used in combination chemotherapy for the treatment of esophageal cancer, which is an off-label indication. It has a black box warning for anaphylactic reactions, which can be managed with epinephrine, corticosteroids, and antihistamines.

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Antineoplastics, Antimicrotubular

Class Summary

These agents prevent cell growth and proliferation. They work by enhancing tubulin dimers, stabilizing existing microtubules, and inhibiting microtubule disassembly.

Docetaxel (Taxotere, Docefrez)

Docetaxel inhibits the depolymerization of tubulin, which inhibits DNA, RNA, and protein synthesis. It can be used in combination with cisplatin and fluorouracil for the treatment of esophageal cancer, which is an off-label indication. It has several black box warnings such as bone marrow suppression, fluid retention, and hypersensitivity reactions.

Use of docetaxel is not recommended in certain patients with hepatic impairment. Patients receiving treatment with docetaxel should be premedicated with corticosteroids the day before administration to help reduce fluid retention and hypersensitivity reactions.

Paclitaxel

Paclitaxel promotes microtubule assembly, interferes with the G2 mitotic phase, and inhibits cell replication. Although not FDA approved, it has been used in combination chemotherapy for the treatment of esophageal cancer. Paclitaxel has an off-label indication for the treatment of adenocarcinoma. Black box warnings for this drug include bone marrow suppression and hypersensitivity reactions.

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Antineoplastics, Anthracycline

Class Summary

Anthracycline antineoplastics inhibit DNA and RNA synthesis by steric obstruction. They intercalate between DNA base pairs and trigger DNA cleavage by topoisomerase II.

Epirubicin (Ellence)

Epirubicin inhibits DNA and RNA synthesis. It can be used off label as part of a combination chemotherapy regimen for the treatment of esophageal cancer. It has several black box warnings, including bone marrow suppression, extravasation, myocardial toxicity, and secondary malignancy. Dosage reduction is recommended in patients with mild to moderate hepatic impairment.

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Antineoplastics, Topoisomerase Inhibitors

Class Summary

These agents prevent cell growth and proliferation. They work by binding to topoisomerase and causing single-strand DNA breaks.

Irinotecan (Camptosar)

Irinotecan binds reversibly to the topoisomerase I–DNA complex and prevents the ligation of the cleaved DNA strand. It can be used as part of combination chemotherapy for the treatment of esophageal cancer, which is an off-label indication. Black box warnings for irinotecan include bone marrow suppression and diarrhea.

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Antineoplastics, Other

Class Summary

This category includes miscellaneous antineoplastic agents that cause cytotoxic activity by various mechanisms of action.

Porfimer (Photofrin)

Porfimer is a photodynamic therapy that causes cytotoxic activity by producing oxygen free-radicals in the presence of laser light. It also can release thromboxane A2, leading to necrosis and vascular occlusion. It is indicated for palliation in patients with partially or completely obstructing esophageal cancer.

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