Esophageal cancer is incurable in most patients. Tumor anatomy must be carefully defined using radiographic and endoscopic techniques. These techniques can also provide useful information to plan palliative treatment. The goals of palliation must be explicitly discussed and defined with the patient and family. Palliative manipulation is best done by a physician with experience in the procedures, after consideration of all available options to ensure effective palliation with minimal risk of complications. Esophageal dilation is an integral part of most palliative treatment programs, either as sole or adjunctive therapy. Dilation can maintain luminal patency in most patients and can be performed easily, effectively, and safely in an outpatient setting. An esophageal prosthesis can further alleviate symptoms in patients in whom more conventional palliative techniques are unsuccessful. Because prosthesis placement is associated with a relatively high rate of complications, it should be reserved for patients with advanced refractory disease or tracheo-esophageal fistula, for whom no other palliative alternatives exist.