July 15, 2026
Although relatively rare, esophageal cancer remains one of the most challenging cancers to treat surgically, often presenting at an advanced stage and requiring complex, multidisciplinary care. Advances in surgical techniques, perioperative management and systemic therapy — including immunotherapy — are now improving outcomes and expanding the number of patients eligible for curative-intent resection.
Thoracic surgeon Luis F. Tapias Vargas, M.D., and medical oncologist Ryan C. Augustin, M.D., are core members of the multidisciplinary esophageal cancer team and part of the Mayo Clinic Comprehensive Cancer Center in Rochester, Minnesota. Together with radiation oncologists, radiologists, pathologists and other specialists, they offer hope to patients who come to Mayo Clinic seeking the latest treatment options.
Setting the stage for complex decision-making
Collaborative discussions within multidisciplinary teams often focus on whether a patient is a candidate for curative-intent surgery — a determination that has become more nuanced as treatment options have expanded. In many cases, the question is not only whether a tumor is resectable but also how to optimize a patient's candidacy for surgery and long-term disease control.
Resectability depends on tumor histology and stage, as well as patient age and comorbidities. In the U.S., gastroesophageal adenocarcinoma is the predominant histologic subtype. Accurate staging relies on comprehensive evaluation, which typically includes:
- CT to assess tumor size and location.
- Endoscopic ultrasound with biopsy of the primary tumor and regional lymph nodes.
- PET scan to evaluate for distant disease.
- Staging laparoscopy with peritoneal washings to detect intra-abdominal spread.
"We expedite testing so cases can be reviewed and treatment started as soon as possible," Dr. Augustin says. "For most patients, we have the necessary information within a week or less."
After review, tumors are generally classified as resectable, unresectable or borderline.
Resectable esophageal tumors
Resectable tumors are confined to the esophagus or locally advanced with limited nodal involvement. Except in very early-stage disease, treatment typically includes neoadjuvant and adjuvant multimodal therapy. In 2025, the standard of care shifted from chemotherapy plus radiation therapy to chemotherapy combined with immunotherapy for eligible patients. Medical oncologists at Mayo Clinic often front-load systemic therapy prior to surgery to maximize dose intensity. This is when patients are best able to tolerate treatment.
Unresectable esophageal tumors
Esophageal tumors are considered unresectable when they invade adjacent structures or demonstrate more-extensive spread. "Careful multidisciplinary discussions usually take place before classifying a tumor as unresectable," Dr. Tapias Vargas says.
Systemic therapy is the cornerstone of care in this setting, with immunotherapies selected based on tumor biomarkers. Ongoing advances in this area continue to translate into meaningful gains in survival.
Borderline resectable esophageal tumors
In some cases, resectability is uncertain. Nodal disease that extends beyond typical surgical margins presents particularly complex management challenges and derives substantial benefit from multidisciplinary input.
"We may pursue more-prolonged neoadjuvant therapy to assess response before committing to surgery," Dr. Augustin says. "Targeted radiation to involved lymph nodes also may be incorporated into the treatment plan."
Expediting recovery after esophageal cancer surgery
Surgery for esophageal and gastroesophageal junction carcinoma is complex and traditionally associated with an extended recovery period. The operation requires access to both the abdominal and thoracic cavities to resect the tumor and regional lymph nodes.
Minimally invasive and robotic approaches have largely replaced open laparotomy and thoracotomy, reducing tissue trauma and improving postoperative outcomes. "By minimizing tissue disruption, we see shorter hospital stays, less pain and fewer complications," Dr. Tapias Vargas says.
A 2021 article in the Journal of the American College of Surgeons showed that outcomes are further optimized at high-volume centers. For esophagectomy, performing 18 procedures annually defines high-volume status. Mayo Clinic surgeons in Rochester perform approximately 80 surgeries each year.
Additional advances include:
Enhanced recovery after surgery
Enhanced recovery after surgery (ERAS) protocols standardize perioperative care and reinforce best practices. At Mayo Clinic, ERAS begins at initial patient contact and extends through postoperative follow-up. Key elements include:
- Early mobilization. Most patients are walking daily, starting the day after surgery at the latest.
- Nutrition optimization. Feeding tubes are used selectively, and many patients resume oral intake within 3 to 7 days. Those requiring enteral nutrition through a feeding tube receive teaching and support. Throughout recovery, patients follow a gradual, individualized diet advancement plan.
- Multimodal pain management. Nonopioid strategies are emphasized.
A 2024 study in The Annals of Thoracic Surgery evaluated an ERAS-based quality initiative at Mayo Clinic to improve morbidity and mortality following esophagectomy, mainly for esophageal cancer. Compared with historical controls, ERAS implementation reduced length of stay by 27% and lowered complication rates from 54% to 35%.
Remote postoperative monitoring
Thoracic surgeons at Mayo Clinic in Rochester were early adopters of remote postoperative monitoring technologies. Remote monitoring brings surgical oversight into the home, enabling early detection of complications such as dehydration, infection or respiratory decline during a critical window following esophagectomy.
"Although the remote monitoring program is new, patients report that staying connected to the care team during early recovery is reassuring," Dr. Tapias Vargas says.
Participating patients receive a tablet-based system and devices to track vital signs and symptoms. Over 30 days, they complete a daily questionnaire that a dedicated nursing team reviews. The first formal postoperative visit occurs just after the remote monitoring period.
Immunotherapy's role in surgical decision-making
Some patients demonstrate robust responses to neoadjuvant chemoimmunotherapy, raising questions about whether an operation is always necessary.
"At most high-volume centers such as ours, surgery remains standard even in cases of complete clinical response," Dr. Augustin says. "An important exception is tumors that are microsatellite instability high. Although only a small fraction of patients fall into this category, the possibility of avoiding surgery is very appealing."
In a 2025 Mayo Clinic study published in JCO Precision Oncology, 17 patients with mismatch repair-deficient and microsatellite instability-high gastroesophageal adenocarcinoma underwent nonoperative management. After a median follow-up of 19.3 months, 88.2% were alive and metastasis-free.
"Whenever we defer surgery, we do so cautiously, knowing that the risk of recurrence is substantial," Dr. Tapias Vargas says. "Patients who choose a nonoperative approach require very close surveillance."
Offering flexibility for patients traveling for care
Patients travel to Mayo Clinic for different aspects of esophageal cancer care. Some receive all their treatment, while others come only for surgical management, which is less widely offered locally.
"We tailor our involvement to each patient's needs and coordinate closely with local teams," Dr. Augustin says. "Often, we provide multidisciplinary evaluations and recommendations with systemic therapy delivered closer to home. We remain available for support and guidance as needed."
Future directions in esophageal cancer care
For surgeons, the future of esophageal cancer care lies not only in refining operative techniques but also in integrating systemic therapy response, biomarker data and real-time patient monitoring into a more adaptive surgical strategy.
"Expanding immunotherapy into earlier stage disease is reshaping surgical decision-making, including how surgeons assess treatment response, determine timing of resection and, in select cases, potentially eliminate the need for surgery," Dr. Tapias Vargas says.
For more information
Ju MR, et al. Defining targets for high-volume esophagectomy centers to improve surgical outcomes. Journal of the American College of Surgeons. 2021;223:S234.
Sims C, et al. Esophagectomy enhanced recovery after surgery initiative results in improved outcomes. Annals of Thoracic Surgery. 2024;117:847.
Sahwan O, et al. Immune checkpoint inhibitors for mismatch repair-deficient gastroesophageal adenocarcinoma: Outcomes and feasibility of nonoperative management at Mayo Clinic. JCO Precision Oncology. 2025;9:e2500492.
Refer a patient to Mayo Clinic.