Role of Nurse Practitioners in Managing Esophageal Cancer, Complications

Nurse practitioners play a central role in helping patients with esophageal cancer understand and manage their disease and treatment complications, emphasized a speaker at the Oncology Nursing Society (ONS) 42nd Annual Congress, held May 4–7 in Denver.

“Nurses who understand the full scope of side effects related to esophageal cancer and the quality-of-life data will be better able to manage these patients,” said Laura A. Pachella, MSN, RN, AGPCNP-BC, AOCNP, of the University of Texas MD Anderson Cancer Center in Houston.

In the United States, esophageal cancer represents 1% of all newly diagnosed malignancies, with an estimated 16,980 new US cases each year; nearly 15,600 patients die from the disease annually. Both the disease and its treatment cause considerable morbidity. Overall 5-year survival is 18%, according to Pachella.

In the United States, smoking and Barrett esophagus (caused by gastroesophageal reflux disease) are known risk factors and obesity and Helicobacter pylori infection are suspected causes.

Esophageal tumors can be asymptomatic until they have reached advanced, locally invasive stages of disease, at which point pain or difficulty in eating can occur. The diagnostic gold standard is endoscopic ultrasound when metastasis is not suspected.

“Treatment for advanced esophageal cancer is the trimodality therapy approach: chemotherapy, radiation, and surgical resection,” Pachella said. “Trimodality therapy gives patients the highest chance for cure, but it’s associated with persistent symptoms and impacts quality of life.”

A patient’s overall health, disease stage and extent, and liver and kidney function are key considerations in treatment planning, she said. Prior radiation is also key as patients frequently have undergone radiotherapy for lung cancer.

In addition to helping with staging esophageal cancer, oncology nurses play a central role in helping patients mitigate the impacts of esophageal tumors and cancer treatment on their quality of life, through education, supportive care and palliation, and survivorship care.

Chemoradiation is associated with radiation esophagitis, dysphagia, and resulting nutritional and hydration challenges. Prophylactic enteral tube placement is common. “Most patients require enteral nutrition following esophagectomy for 4 to 6 weeks,” Pachella said.

Esophagectomy can cause esophageal strictures, prompting dilation with upper endoscopy and steroid injections, as well as “dumping syndrome,” which involves cramping, bloating, nausea, diarrhea, and even fainting and heart palpitations. Gastroparesis and reflux are also common challenges, Pachella noted.

Postoperative pneumonia and anastomotic leak also sometimes occur.

“Daily functioning may change in regard to diet, swallowing, bowel, and fatigue,” she noted. The post-esophagectomy diet avoids high-carbohydrate meals and dairy products, and emphasizes a shift to smaller, more frequent meals. It also requires avoiding liquids with meals because fluids can increase gastric motility.

Patients should be prepared for likely changes in their sleep habits and physical appearance, such as those associated with weight loss, and the need for palliative interventions such as esophageal stents or dilation. Symptom control is associated with better quality of life.