Palliation of malignant dysphagia: stent or radiotherapy?

Palliation of dysphagia forms the cornerstone in treating incurable esophageal cancer. The ultimate goal is to provide rapid and sustained relief of dysphagia. Optimal management is however a challenge as a single modality providing both rapid and sustained relief is not readily available. The two most commonly used modalities for palliative treatment of dysphagia include esophageal stent placement and radiotherapy. Treatment choice primarily depends on life-expectancy and dysphagia severity. Radiotherapy is preferred in those with a life-expectancy of more than three months as it is superior to stent placement with regard to effect duration. Regarding the former, short cycle external-beam radiotherapy (EBRT) is currently preferred over single-dose brachytherapy (BT) because of better clinical outcomes, lower toxicity and easier application. In contrast, if life-expectancy is less than three months, immediate relief of dysphagia is important and self-expandable metal stent (SEMS) placement is the preferred treatment. Although combining these two treatment modalities seems promising, evidence to support this is lacking. Placement of an irradiation stent has been suggested for patients with a reasonable life-expectancy, although placement requires a specifically-designed unit and experienced personnel. The research agenda should focus on further improving radiotherapy techniques, stent design, and effectiveness of combination therapy aiming to provide rapid and sustained dysphagia relief while maintaining quality of life.