Updates in adjuvant treatment after oesophageal cancer surgery

Treatment after oesophagectomy is changing as evidence clarifies which patients benefit from additional systemic therapy. The key distinction is whether cancer remains in the surgical specimen after preoperative chemoradiotherapy, and whether the patient can safely receive immune checkpoint inhibition. Learn more about リウマチ性疾患の心不全リスクと心エコー検査の活用.

For Australian clinicians, these decisions sit within a multidisciplinary team involving upper gastrointestinal surgeons, medical and radiation oncologists, pathologists, radiologists, dietitians and specialist nurses. Practice can differ between a tertiary centre in Melbourne, Sydney or Brisbane and a regional service, where travel, infusion capacity and access to clinical trials influence the plan.

Why postoperative treatment is changing

Historically, surgery was followed by surveillance or further chemotherapy, depending on the original regimen and pathological findings. Recurrence risk remains substantial, particularly when there is residual tumour in the oesophagus or lymph nodes after neoadjuvant chemoradiation.

The landmark CheckMate 577 findings established a new option: adjuvant nivolumab improved disease-free survival after complete resection in patients with residual pathological disease. This applies to people treated with neoadjuvant chemoradiotherapy followed by surgery, rather than to every patient who has undergone an oesophagectomy.

The benefit is clinically important because relapse may occur locally or through distant metastases, often within the first two years. Postoperative treatment therefore aims to eliminate microscopic disease while the patient is recovering from a demanding operation.

Evidence behind immunotherapy

Nivolumab is a programmed death-1, or PD-1, inhibitor. In the postoperative setting, it helps restore T-cell activity against tumour cells that may have survived chemoradiotherapy and resection. The treatment course used in the pivotal study extended for up to one year, with dosing schedules adjusted to the clinical setting.

Pathological response is central to eligibility. Patients with a complete response after chemoradiation generally do not match the evidence base used for adjuvant nivolumab, while those with residual disease may derive a meaningful reduction in recurrence risk. Histology, resection quality and performance status also matter.

The result has broadened the role of immunotherapy in oesophageal and gastro-oesophageal junction cancer. It has also made close communication between the surgeon, pathologist and oncologist essential, since a treatment decision can depend on details in the final pathology report.

Selecting patients in practice

Before starting adjuvant therapy, clinicians assess recovery from surgery, nutritional status, renal and hepatic function, autoimmune history and previous treatment toxicity. Ongoing anastomotic problems, infection, poor oral intake or severe deconditioning may require a short delay and active supportive care.

Tumour histology remains relevant. Squamous cell carcinoma and adenocarcinoma may respond differently to systemic treatments, while tumour location and gastro-oesophageal junction classification can affect the evidence considered. Biomarkers such as PD-L1 expression may support broader treatment decisions, although they do not replace the pathological criteria established for postoperative nivolumab.

A careful history should identify pre-existing thyroid, bowel, lung, liver and rheumatological conditions. Cardiac symptoms also deserve attention; when echocardiography is clinically indicated, a cardiac assessment resource can provide useful background for evaluating heart failure risk in patients with inflammatory disease.

Chemotherapy still has a role

Immunotherapy does not eliminate the role of cytotoxic treatment. For some patients, perioperative chemotherapy such as FLOT is used before and after surgery, particularly in resectable adenocarcinoma managed without neoadjuvant radiotherapy. The choice depends on tumour stage, anatomical site, fitness and local multidisciplinary expertise.

Postoperative chemotherapy may be difficult to deliver because swallowing, weight loss, neuropathy, fatigue and complications can reduce tolerance. A treatment plan should therefore be reassessed after surgery rather than applied automatically from the preoperative schedule.

For patients who received neoadjuvant chemoradiation and have a complete pathological response, observation may remain appropriate. Surveillance should be structured and should include symptom review, nutritional assessment and investigation of findings that suggest recurrence.

Australian implementation

In Australia, access is shaped by Therapeutic Goods Administration approval, Pharmaceutical Benefits Scheme arrangements, hospital protocols and the availability of infusion services. A patient treated at Peter MacCallum Cancer Centre, Royal Prince Alfred Hospital or the Royal Adelaide Hospital may have a different pathway from someone travelling several hours from regional New South Wales or rural Queensland.

The cost of travel, accommodation and time away from work can affect adherence to a year of intravenous treatment. Telehealth can support reviews, but blood tests, infusion appointments and management of immune-related toxicity still require reliable local coordination. Plain language matters too: many patients will describe an oesophagectomy as “a big op” and need clear advice about appetite, reflux and fatigue.

Australian teams also need to account for Aboriginal and Torres Strait Islander patients who may face additional distance, cultural and continuity-of-care barriers. Linking metropolitan specialists with local hospitals, Aboriginal health services and general practitioners can make postoperative treatment safer and more practical.

Monitoring treatment and recovery

Immune checkpoint inhibitors can cause inflammation in otherwise healthy organs. Patients should report new diarrhoea, persistent cough, breathlessness, jaundice, severe rash, marked fatigue or changes in temperature tolerance. Early recognition may prevent a manageable adverse effect from becoming a serious complication.

Useful baseline and follow-up checks commonly include:

• Full blood count, electrolytes, liver enzymes and thyroid function
• Weight, hydration, swallowing ability and dietary intake
• Review of bowel, respiratory, skin, neurological and endocrine symptoms
• Assessment of corticosteroid or other immunosuppressant use

Supportive care should continue alongside cancer treatment. Practical priorities include:

• Dietitian input for weight maintenance and micronutrient needs
• Exercise and physiotherapy after prolonged hospitalisation
• Smoking cessation and moderation of alcohol
• A written escalation plan shared with the GP and emergency service

Research and future directions

Current research is examining how to combine immunotherapy with chemotherapy, targeted agents and more precise biomarker testing. Circulating tumour DNA may eventually help identify minimal residual disease before radiological recurrence becomes visible, although it is not yet a routine basis for postoperative treatment decisions.

Trials are also exploring treatment before surgery, organ-preserving approaches and strategies for patients with locally advanced disease who are not suitable for an operation. Better molecular classification may help distinguish patients who need intensified therapy from those who can avoid unnecessary toxicity.

For an Australian congress audience, the practical message is to interpret emerging evidence through local pathways, trial availability and patient priorities. After resection, review the pathology carefully, confirm the preoperative treatment received, assess recovery and comorbidities, then make the adjuvant decision through a documented multidisciplinary plan.