What is Esophageal Cancer
Esophageal cancer is an abnormal growth of cancerous (malignant) cells in the part of the body that moves food from the mouth to the stomach (esophagus).
How common is esophageal cancer?
Cancer of the esophagus accounts for 1% of all newly diagnosed cancers in the United States, and the incidence has continued to rise in the last 30 years.
An estimated 13,000 new cases of carcinomas of the esophagus were diagnosed in men and 3500 new cases in women in 2009. Approximately 11,500 men and 3000 women will die from the disease. It is seven times more common in men than women and is the seventh leading cause of death from cancer among men.
Whereas squamous cell carcinoma accounted for most cancers of the esophagus 40 years ago, adenocarcinoma now represents more than 70% of such tumors in the United States. This is primarily caused by the striking increase in incidence of adenocarcinoma among white men older than 60 years.
The cause for the rising incidence and changing demographics is unknown, although part of the rise is due to the increasing incidence of Barrett’s esophagus and resulting adenocarcinoma in the distal esophagus.
What are the causes?
The exact cause of esophageal cancer is not known.
What increases the risk?
Risk factors for esophageal cancer include:
- Being older than 65 years of age.
- Being male.
- Using any tobacco products, including cigarettes, chewing tobacco, and e-cigarettes.
- Excessive alcohol use.
- Eating a diet that is low in fruits and vegetables.
- Being overweight or obese.
- Having a damaged esophagus due to exposure to poisons (toxins).
- Having a history of other types of cancer.
- Having conditions that cause damage or irritation to the esophagus. These conditions include:
- Acid reflux.
- Barrett’s esophagus.
- Plummer–Vinson syndrome.
- HPV (human papillomavirus).
Risk factors for squamous cell carcinoma include tobacco use and excessive alcohol consumption, which appear to have a synergistic effect in its pathogenesis.
Additionally, N-nitroso food compounds, achalasia, caustic injury, low socioeconomic status, and prior thoracic irradiation have been associated with an increased risk of the disease.
Risk factors for the development of distal esophageal adenocarcinoma are less clear.
The presence of Barrett’s esophagus is associated with an increased risk of developing adenocarcinoma, and recently a population-based case-control study from Sweden has demonstrated that symptomatic chronic GE reflux is also a risk factor.
What are the symptoms of Esophageal Cancer?
Symptoms may include:
- Trouble swallowing.
- Chest or back pain.
- Weight loss without trying (unintentional weight loss).
- Hoarse voice.
- Coughing. This may include coughing up blood.
- Vomiting. This may include vomiting up blood.
- Stools (feces) that look black or tarry due to bleeding into the esophagus.
- Bone pain.
How is this diagnosed?
Esophageal Cancer may be diagnosed based on:
- Your symptoms and medical history.
- A physical exam of the throat. A tube with a light and camera on the end of it (endoscope, bronchoscope, or laryngoscope) may be used to examine your throat and esophagus and to check if the cancer has spread to other areas, such as the lungs. Tissue samples may be removed (biopsy) and examined for cancer cells.
- A procedure in which you swallow a solution (barium) and then X-rays are done to evaluate the esophagus (barium swallow). The barium shows up well on X-rays, making it easier for your health care provider to see possible problems.
tests, such as:
- CT scan.
- PET scan.
Your cancer will be assessed (staged) to determine how severe it is and how much it has spread.
How is Esophageal Cancer treated?
Treatment for esophageal cancer depends on the type and stage of the cancer. Treatment may include one or more of the following:
- Surgery to remove small tumors within the esophagus.
- Surgery to remove part of the esophagus (esophagectomy).
- Surgery to remove part of the esophagus and the upper portion of the stomach (esophagogastrectomy).
- Medicines that kill cancer cells (chemotherapy).
- High-energy rays that kill cancer cells (radiation therapy).
- Targeted therapy. This targets specific parts of cancer cells and the area around them to block the growth and spread of the cancer. Targeted therapy can help limit damage to healthy cells.
- Medicines that help your body’s disease-fighting system (immune system) fight the cancer cells (immunotherapy).
- A procedure to remove part of the inner lining of the esophagus (endoscopic mucosal resection).
- A procedure in which you are given IV medicine and then an endoscope is used to shine a special type of light onto the esophagus (photodynamic therapy). The light changes the medicine into a chemical that destroys cancer cells.
- A procedure in which a small balloon is inflated in the esophagus (radiofrequency ablation). The balloon uses an electric current to heat and destroy the cells in the lining of the esophagus.
What are the surgical approaches to the patient with esophageal cancer?
Surgery is the primary treatment modality for esophageal cancer. In the United States, esophageal resection is most commonly performed, using one of the following approaches:
- • Transhiatal esophagectomy involves both a midline laparotomy and left cervical incision. The short gastric and left gastric arteries are ligated, whereas the right gastric artery and right gastroepiploic arcade are carefully preserved to allow a well vascularized gastric conduit to reach to the neck. The esophagus is resected through the abdominal and neck incisions. A cervical GE anastomosis is performed through the cervical incision. The main advantage of this approach is avoidance of a thoracic anastomosis because a cervical leak carries much less morbidity than for a thoracic leak.
- • Ivor-Lewis esophagectomy requires a midline laparotomy and a right posterolateral thoracotomy. En bloc resection is performed from the hiatus to the apex of the chest just above the azygos vein. A GE anastomosis is performed in the right chest.
- • Multi-incision esophagectomy is performed less often and requires a midline laparotomy, right thoracotomy, and cervical incision.
- • Left thoracoabdominal esophagectomy involves one incision extended across the abdomen and posterolateral chest for en block resection of the GE junction.
- • Minimally invasive esophagectomy involves right thoracoscopic esophageal and lymph node bearing tissue mobilization, laparoscopic mobilization of the stomach, and a high intrathoracic or cervical anastomosis.
Regardless of the incision approach, the same operative procedure is performed, that is, esophagogastrectomy with regional lymph node resection. Although each approach has its proponents, transhiatal esophagectomy is the most common procedure performed, with a decreased incidence of pulmonary complications, the reduced morbidity and mortality of an anastomotic leak, and no evidence that a radical lymphadenectomy benefits overall survival cited as the most compelling arguments.
When is neoadjuvant therapy appropriate in the treatment of patients with esophageal carcinoma?
At most institutions, neoadjuvant treatment is currently recommended for stage III esophageal cancer or greater. There are different modalities of neoadjuvant therapy for esophageal cancer treatment, including either radiation alone (dose used 50 Gy), chemotherapy alone (chemotherapeutic agents used are cisplatin, 5-fluorouracil, carboplatin, paclitaxel, etoposide, or epirubicin), or chemoradiation prior to surgery. Preoperative radiation alone was found to have no significant benefit compared with surgery alone. Clinical trials have shown that neoadjuvant chemoradiation or chemoradiation were found to have statistically significant benefits for survival compared with surgery alone . Chemotherapy versus chemoradiation have been compared in clinical trials but no statistical difference was shown. Potential advantages of neoadjuvant therapy include cancer down-staging, increased resectability, and reduction in micrometastasis. In addition, the chemotherapeutic agents used all possess radiosensitizing properties. However, more studies are needed to verify the effectiveness of this treatment strategy.
Nonsurgical options for treatment of esophageal cancer
Nonsurgical options for treatment of esophageal cancer can be divided into interventions for palliation and those for cure. Precancerous lesions or superficial cancers confined to the mucosa without evidence of metastatic spread can be cured with local therapy. Appropriate candidates include patients with limited HGD and carcinoma in situ associated with Barrett’s esophagus. In these cases, alternative therapies, such as endoscopic mucosal resection, endoscopically applied laser, photodynamic therapy, or argon plasma coagulation, are ablative therapies that have been curative in certain cases. When curative treatment is not possible, in addition to systemic chemotherapy, palliative care measures have included external beam radiation, endoluminal brachytherapy, endoluminal stenting, laser ablation, and photodynamic therapy.
What is the survival of patients with esophageal cancer?
The overall 5-year survival in patients with esophageal cancer is reported between 13% and 17%. Those patients with stage I disease have an excellent 5-year survival, approximately 80%. The 5-year survival for stage II and stage III disease is 20% to 30% and 10%, respectively. Those with stage IV disease live rarely beyond 18 months. Unfortunately, most esophageal cancers present at later stages with locally advanced disease or metastases, when cure is not possible and palliation is the only treatment option.
Follow these instructions at home:
- Do not use any products that contain nicotine or tobacco, such as cigarettes and e-cigarettes. If you need help quitting, ask your health care provider.
- Do not drink alcohol.
- Try to eat regular, healthy meals. Some of your treatments might affect your appetite and your ability to swallow. If you are having problems eating or if you do not have an appetite, meet with a dietitian.
- Take over-the-counter and prescription medicines only as told by your health care provider.
- Consider joining a support group for people who have been diagnosed with esophageal cancer.
- Work with your cancer care team to manage any side effects of treatment.
- Keep all follow-up visits as told by your health care provider. This is important.
Where to find more information
- American Cancer Society: www.cancer.org
- National Cancer Institute (NCI): www.cancer.gov
Contact a health care provider if:
- You have more problems swallowing or eating.
- You have new fatigue or weakness.
- You continue to lose weight unintentionally.
- You have a fever.
Get help right away if:
- You have pain that suddenly gets worse.
- You have trouble breathing.
- You vomit blood or black material that looks like coffee grounds.
- You have black stools.
- You faint.
- Esophageal cancer is an abnormal growth of cancerous (malignant) cells in the part of the body that moves food from the mouth to the stomach (esophagus).
- During diagnosis, a tube with a light and camera on the end of it (endoscope, bronchoscope, or laryngoscope) may be used to examine your throat and esophagus.
- Do notuse any products that contain nicotine or tobacco, such as cigarettes and e-cigarettes. If you need help quitting, ask your health care provider.
- Work with your cancer care team to manage any side effects of treatment.