Certain very early tumors, limited to the submucosa (the superficial layer of the esophagus), may be treated with endoscopic resection. More commonly, people present with advanced stage disease because symptoms often develop only after the tumor has grown to a large size or has spread. There are a number of different modalities that can be used to treat esophageal cancer including surgery, radiation, and chemotherapy. However, in people who can tolerate it, combined modality is preferred. When the esophagus is removed, the stomach is pulled up into the chest to keep the passageway for food intact. Not only is there a risk of infection and bleeding from the surgery itself, but the recovery period after surgery can be difficult. Additionally, there is the risk of a leak forming at the new connection that is formed between the stomach and the remaining portion of the esophagus (known as an anastamosis), which can then require further surgery and potentially lead to very serious complications. Though the results of these studies are somewhat mixed, it is thought that both radiation and chemotherapy add a benefit. Therefore, radiation therapy (for local tumor control) and chemotherapy (for distant control as well as to improve the effectiveness of radiation therapy) is almost always recommended either before or after the surgery.