Comparing Proton Therapy to Photon Radiation Therapy for Esophageal Cancer

Inclusion Criteria:

• PRIOR TO STEP 1 REGISTRATION:

• Histologically proven diagnosis of adenocarcinoma or squamous cell carcinoma of thethoracic esophagus or gastroesophageal junction (Siewert I-II)

• Stage I-IVA, excluding T4b, according to the American Joint Committee on Cancer (AJCC) 8th edition based on the following diagnostic workup:

• History/physical examination

• Whole-body fludeoxyglucose F-18 (FDG)-positron emission tomography (PET)/computed tomography (CT) with or without contrast (preferred) orchest/abdominal (include pelvic if clinically indicated) CT with contrast

• For patients who DID NOT receive induction chemotherapy, scan must occurwithin 30 days prior to Step 1 registration

• For patients who DID receive induction chemotherapy, scan must occur:

• Within 30 days after final induction chemotherapy dose; OR

• Within 30 days prior to Step 1 registration

• Note: Patients who had prior endoscopic mucosal resection (EMR) with adiagnosis of AJCC stage I-IVA, excluding T4b, esophageal cancer areeligible

• Surgical consultation to determine whether or not the patient is a candidate forresection after completion of chemoradiation

• Induction chemotherapy for the current malignancy prior to concurrent chemoradiationallowed if last dose is no more than 90 days and no less than 10 days prior to Step 1 registration; only FOLFOX, CAPOX, durvalumab-fluorouracil, leucovorin, oxaliplatinand docetaxel (FLOT) (D-FLOT) and FLOT will be allowed as the induction chemotherapyregimen

• Age ≥ 18

• Zubrod performance status 0, 1, or 2

• Absolute neutrophil count (ANC) (within 30 days prior to Step 1 registration)

• For patients who DID NOT receive induction chemotherapy: ANC ≥ 1,500 cells/mm^3

• For patients who DID receive induction chemotherapy: ANC ≥ 1,000 cells/mm^3

• Platelets (within 30 days prior to Step 1 registration)

• For patients who DID NOT receive induction chemotherapy: Platelets ≥ 100,000/uL

• For patients who DID receive induction chemotherapy: Platelets ≥ 75,000/uL

• Hemoglobin ≥ 8.0 g/dl (Note: The use of transfusion or other intervention to achieveHgb ≥ 8.0 g/dl is acceptable) (within 30 days prior to Step 1 registration)

• Serum creatinine ≤ 1.5 X upper limit of normal (ULN) or creatinine clearance > 40mL/min estimated by Cockcroft-Gault formula (within 30 days prior to Step 1registration)

• Total bilirubin ≤ 1.5 x upper limit of normal (ULN) (within 30 days prior to Step 1registration)

• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤ 3 x ULN (within 30 days prior to Step 1 registration)

• Negative pregnancy test (serum or urine) within 14 days prior to Step 1 registrationfor women of child bearing potential

• The patient or a legally authorized representative must provide study-specificinformed consent prior to study entry

Exclusion Criteria:

• Cervical esophageal cancers arisen from 15-18 cm from the incisors

• Patients with T4b disease according to the AJCC 8th edition

• Definitive clinical or radiologic evidence of metastatic disease

• Any active malignancy within 2 years of study registration that may alter the courseof esophageal cancer treatment

• Prior thoracic radiotherapy that would result in overlap of radiation therapy fields

• Severe, active co-morbidity defined as follows:

• Active uncontrolled infection requiring IV antibiotics at the time of Step 1registration

• Uncontrolled symptomatic congestive heart failure, unstable angina, or cardiacarrhythmia not controlled by any device or medication at the time of Step 1registration

• Myocardial infarction within 3 months prior to Step 1 registration

• Pregnant and/or nursing females

• Human immunodeficiency virus (HIV) positive with CD4 count < 200 cells/microliter.Note that patients who are HIV positive are eligible, provided they are undertreatment with highly active antiretroviral therapy (HAART) and have a CD4 count ≥ 200 cells/microliter within 30 days prior to registration. Note also that HIVtesting is not required for eligibility for this protocol. This exclusion criterionis necessary because the treatments involved in this protocol may be significantlyimmunosuppressive

• PRIOR TO STEP 2 REGISTRATION:

• Unable to obtain confirmation of payment coverage (insurance or other) for eitherpossible radiation treatment