Oesophageal cancer: what is it?
Oesophageal cancer (also called cancer of the oesophagus) is a malignant tumour that grows in the lining of the oesophagus.
The oesophagus (the gullet) is the tube that carries food from the mouth down into the stomach using a series of muscular movements.
Oesophageal cancer is more common in men than women, and usually affects people older than 60 years of age.
Symptoms of oesophageal cancer
Many people do not experience any discomfort or noticeable symptoms early on with oesophageal cancer. However, as the cancer progresses the following symptoms may develop.
- Difficult or painful swallowing that may be accompanied by a feeling that food or fluids are getting stuck in the throat. The difficulty swallowing is usually first noticed with solids and then progresses until there is difficulty swallowing soft foods and also liquids.
- Weight loss is common because of the difficulty in swallowing food and liquids.
- Regurgitation of food, or worsening indigestion or heartburn.
- Bleeding, which can result in vomiting or coughing up blood, black-coloured faeces (caused by blood that has passed through the digestive tract), and anaemia.
- Coughing or choking, usually after swallowing.
- Hoarseness of the voice.
- Chest or upper abdominal pain or discomfort, when swallowing or at other times.
You should always check with your doctor if you have any difficulty swallowing or have constant episodes of reflux, or if you experience any of the above symptoms.
Pneumonia is a possible complication of oesophageal cancer, caused by food going down the airway instead of the oesophagus and getting into the lungs (doctors call this aspiration pneumonia).
Types of oesophageal cancer
Two types of cancer, squamous cell carcinoma and adenocarcinoma, make up 90 per cent of all oesophageal cancers. Oesophageal cancer can occur in any section of the oesophagus.
Squamous cell carcinoma
Most cancers in the top or middle part of the oesophagus are squamous cell cancers. They are called this because the cells lining the top part of the oesophagus are squamous cells. Squamous means scaly.
Most cancers at the end of the oesophagus that joins the stomach are adenocarcinomas. Adenocarcinomas are often found in people who have a condition called Barrett’s oesophagus. In Barrett’s oesophagus, long term gastro-oesophageal reflux damages the normal squamous cells that line the oesophagus by repeatedly bathing them in acidic stomach contents. Over time the squamous cells are replaced by cells more like the ones in the stomach and small intestine. It is in these new cells, the so-called Barrett’s metaplasia, that adenocarcinomas can develop.
The cause of oesophageal cancer is not fully understood, but there are a number of risk factors and conditions that can increase your risk of oesophageal cancer. These include the following.
- Gastro-oesophageal reflux disease (GORD, or reflux).
- Barrett’s oesophagus (a condition caused by repeated episodes of reflux that results in changes to the usual cell lining of the oesophagus).
- Alcohol: drinking large quantities of alcohol on a regular basis.
- Eating a diet that is low in fresh fruits and vegetables.
- Regularly consuming very hot drinks or foods.
- Obesity or being overweight.
- Vitamin and other nutritional deficiencies.
- Being exposed to certain chemicals, such as nitrosamines.
- Achalasia — a condition where the muscles of the lower oesophageal sphincter (the ‘valve’ that controls food passing from the oesophagus to the stomach) can’t relax properly and so food builds up in the oesophagus and doesn’t pass to the stomach. Also, the normal waves of muscle contractions that propel food down the oesophagus don’t work properly, also adding to the build-up of food.
- Plummer-Vinson syndrome — a rare condition that causes anaemia, tongue abnormalities and oesophageal webs (abnormal protrusions of tissue into the oesophagus that interfere with swallowing).
Tests and diagnosis
Early detection of oesophageal cancer is extremely important as it improves the chance of successful treatment.
Based on your symptoms and physical examination, your doctor may recommend you have an endoscopy to examine the oesophagus. An endoscope is a narrow tube with a camera on the end that can be used to view the oesophagus and stomach and take small tissue samples (biopsies).
If oesophageal cancer is diagnosed, further tests, such as a CT scan, may be recommended to determine whether the cancer has spread. This is called staging, and will impact on the treatment that is recommended.
Treatment options for oesophageal cancer
Treatment of oesophageal cancer will depend on the size of the cancer, whether it has spread, your age and general state of health. Oesophageal cancer is best treated if found in its earliest stages, before it has spread to other parts of the body. Unfortunately, oesophageal cancer is a serious condition and the long-term survival rate is often not good, even with treatment.
The type of surgery recommended will depend on the size and extent of the tumour. For very small, early stage tumours, the tumour (and a margin or healthy surrounding tissue) may be removed endoscopically (using an endoscope – a long, thin instrument with a camera on the end that can be used to view the oesophagus).
For larger tumours, the section of the oesophagus that contains the cancer is removed: this is called an oesophagectomy. Sometimes the upper part of the stomach is also removed. Nearby lymph nodes and other tissue in the area will also be removed to prevent the cancer spreading.
If a section of the oesophagus is removed, the remaining healthy part of the oesophagus will be connected to the stomach. Sometimes the surgeon will make a tube out of the stomach or a section of bowel and join it to the remaining oesophagus. Surgery for oesophageal cancer is a major operation that will need considerable post-surgery treatment and recovery time.
In cases where the cancer is blocking the oesophagus but it is not possible to remove the cancer, the surgeon may insert an expandable tube (called a stent) to hold open the sides of the oesophagus. Alternatively, the oesophagus can be dilated and widened. A laser may also be used to destroy any cancer blocking the oesophagus.
Radiotherapy (high energy X-rays)
Radiotherapy can be used alone or in combination with surgery or chemotherapy. It can be used to treat the cancer with the intention of cure, or to treat complications from advanced oesophageal cancer, such as obstruction of the oesophagus.
Radiotherapy can be given as an external beam or from radioactive rods placed directly into the oesophagus using an endoscope. Doctors call this brachytherapy.
While radiotherapy is directed so that the cancerous area receives the highest dose, the surrounding tissue is still affected and this is a cause of side effects (such as skin reactions and damage to nearby organs).
Chemotherapy uses medications to kill or slow the growth of the cancer cells. The medications may be taken as a pill, or by injection into the body.
Chemotherapy may be used with radiotherapy (chemoradiotherapy) or without radiotherapy. Chemoradiotherapy can be used before or after surgery.
Side effects depend on which chemotherapy medicines you take. Generally speaking, chemotherapy affects some healthy cells as well as cancer cells, especially those that are fast growing (such as those lining the digestive tract and bone marrow) causing side effects such as mouth ulcers, nausea, tiredness and susceptibility to infection.
Prevention of oesophageal cancer
You can help to prevent or minimise the risk of oesophageal cancer by eliminating risk factors from your lifestyle.
- Smoking is a major risk factor, so if you smoke, you should stop.
- Heavy alcohol intake is also a major risk, so cutting down or eliminating your intake of alcohol is also recommended.
- Also, it is always wise to eat a well-balanced diet, including a variety of fruits and vegetables.
- Lose weight if you are overweight – your doctor can advise you on the best way to lose weight and keep it off.
Longstanding gastro-oesophageal reflux disease can cause Barrett’s oesophagus, which is a major risk factor for oesophageal cancer. If you have been diagnosed with Barrett’s oesophagus, your doctor will need to monitor this condition to detect any changes that may indicate that cancer is developing. This may involve having regular screening endoscopies. People with oesophageal cancer detected in the early stages through screening have a good chance of successful treatment with less invasive procedures.
2. MayoClinic. Esophageal cancer (updated 15 May 2014). http://www.mayoclinic.com/health/esophageal-cancer/DS00500 http://www.mayoclinic.org/diseases-conditions/esophageal-cancer/basics/definition/con-20034316 (accessed Nov 2015).
3. NHS Choices. Oesophageal cancer (updated 30 Jun 2014). http://www.nhs.uk/conditions/cancer-of-the-oesophagus/pages/introduction.aspx (accessed Nov 2015).