Consultant, Surgical Oncology, Artemis Hospitals, Gurugram
Part 8 of 10 in Diagnosis and Management of Esophageal Cancer
Immunotherapy in Esophageal Cancer: Where the Evidence Stands Today
September 6, 2026
Immunotherapy has already reshaped treatment in several cancers, and doctors on the call were keen to know exactly where it currently fits into esophageal cancer specifically, since the honest answer is that its role is well defined in one setting and still genuinely unproven in another.
Established: Adjuvant Therapy for Residual Disease
Immunotherapy's role is currently established in the adjuvant setting, and more so for esophageal squamous cell carcinoma than for adenocarcinoma. A trial supporting adjuvant nivolumab showed that a patient who has completed neoadjuvant chemoradiation or perioperative chemotherapy, gone on to surgery, and is found to still have residual disease benefits from adjuvant nivolumab, with a reduced chance of disease recurrence. If a patient has no residual disease after treatment, adjuvant nivolumab is not advocated. The effect was more pronounced in squamous cell carcinoma, though it is also applicable to adenocarcinoma.
Still Experimental: Immunotherapy Before Surgery
In the neoadjuvant setting, meaning immunotherapy given before surgery rather than after it, the role remains experimental and is one of the genuinely unanswered questions in the field right now. Immunotherapy has already proven its value in lung cancer management and in the adjuvant setting for esophageal cancer, so there is real reason to expect it could improve outcomes and survival if incorporated into pre-operative treatment as well, but that has not yet been established in a way that changes practice.
What No Residual Disease Usually Means
For most patients who complete perioperative chemotherapy, perioperative chemotherapy with radiation, or neoadjuvant chemoradiation and are found to have no residual disease at surgery, no further treatment is typically needed at all. Adjuvant immunotherapy is reserved specifically for the subset with residual disease, not offered as a blanket add-on to everyone who completes neoadjuvant therapy.
This article is based on a Jivo Masterclass session conducted by Dr. Preeti Vijayakumaran, Consultant, Surgical Oncology, Artemis Hospital, Gurugram. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
This guide is based on a live Jivo Masterclass: Dr. Preeti Vijayakumaran taught doctors across Africa on March 16, 2025.
FROM THE LIVE Q&A
Dr. Dinaol Dinegde
Based on your experience, what do you recommend to junior doctors about such an annoying disease of our patients?
Dr. Preeti Vijayakumaran
There is a lot of ignorance in our community, especially in our country, about a complex disease like esophageal cancer. Patients have early, subtle symptoms of difficulty swallowing, but they are often ignored and mistaken for some other common ailment. The need for awareness is foremost. As doctors, we should involve ourselves in educating more and more of the public about the disease, its diagnosis and the treatments available, so that if it is detected early, we can offer patients the maximum curative options.
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Frequently Asked Questions
In routine practice we frequently encounter cases of PPD poisoning due to suicide attempts, which lead to caustic esophageal injury resulting in chronic esophagitis. In such cases, can chronic esophagitis be considered a precancerous lesion?▼
That is a very valid question. Even in our community we see a lot of cases of caustic esophageal injury, and this chronic esophagitis can eventually lead to stricturous disease and become a predisposing cause for esophageal cancer. Patients who survive such an injury and go on to develop stricturous disease should be kept on a very stringent surveillance protocol.
Is there any specific age at which to start screening by endoscopy or another modality?▼
In our practice, screening is recommended after the age of 35 to 40 years, particularly for patients with reflux symptoms or a risk of Barrett's esophagus, though this is a variable number depending on institutional protocol. In practice, we take these patients up for endoscopic mapping: any area showing dysplastic change is biopsied. If there is no evidence of dysplasia after multiple biopsies, the patient is kept on surveillance. Low-grade dysplasia is followed up. High-grade dysplasia in a flat lesion under 2 cm is ablated, and high-grade dysplasia over 2 cm, or with a nodular appearance, is taken for endoscopic resection with histopathology follow-up on the specimen.
In this case of caustic injury from PPD poisoning, what preventive measures should be taken?▼
Most of these patients go on to develop stricturous disease, leading to significant dysphagia and a chronic inability to take oral nutrition. In such patients, an esophagectomy with a neo-esophagus is offered. In patients who do not develop stricturous disease, six-monthly endoscopic evaluation with biopsy of any suspicious area is done instead, and further imaging is not required unless a biopsy proves malignancy.
How do you differentiate gastroesophageal junction cancer and lower esophageal cancer, and the difference in their care?▼
The protocol is endoscopic mapping. The endoscopist localises exactly where the tumour sits relative to the GE junction, using a standard landmark of around 40 cm from the incisors, which varies slightly with the patient's own oesophageal length. Once that is determined, the malignancy is mapped against the gastroesophageal junction, and this is cross-checked against the axial imaging. If there is any disagreement between the endoscopic and imaging findings, the axial imaging representation is preferred to finalise the diagnosis.
What is the role of immunotherapy in esophageal cancer?▼
Immunotherapy's role is currently established in the adjuvant setting, more so for esophageal squamous cell carcinoma. A patient who completes neoadjuvant therapy, undergoes surgery, and is found to have residual disease is followed with adjuvant nivolumab. If there is no residual disease, adjuvant nivolumab is not advocated. In the neoadjuvant setting, the role of immunotherapy is still experimental and yet to be answered.
When is immunotherapy currently used in esophageal cancer?▼
In the adjuvant setting, for patients with residual disease after neoadjuvant chemoradiation or perioperative chemotherapy followed by surgery, particularly for squamous cell carcinoma.
Is immunotherapy used before esophageal cancer surgery?▼
Not as standard practice yet. Neoadjuvant immunotherapy remains experimental and is one of the field's open questions.
Does everyone who has surgery for esophageal cancer need adjuvant immunotherapy?▼
No. It is reserved for patients found to have residual disease after treatment; those with no residual disease typically need no further treatment.
In This Series: Diagnosis and Management of Esophageal Cancer
- 1.Diagnosis and Management of Esophageal Cancer
- 2.Early Warning Signs and Symptoms of Esophageal Cancer
- 3.How Esophageal Cancer Is Diagnosed and Staged
- 4.Telling Gastroesophageal Junction Cancer Apart From Lower Esophageal Cancer
- 5.Treating Early-Stage Esophageal Cancer: When Endoscopy Can Replace Surgery
- 6.Managing Locally Advanced Esophageal Cancer: What the Major Trials Show
- 7.Esophagectomy: How the Surgery Is Performed, and the Shift Toward Robotic Techniques
- 8.Immunotherapy in Esophageal Cancer: Where the Evidence Stands Today
- 9.Screening, Prevention and Risk Factors for Esophageal Cancer
- 10.Life After Treatment: Surveillance for Esophageal Cancer and Managing Recurrence