Esophageal cancer

What is esophageal cancer?

Esophageal cancer is the abnormal growth of cells in the esophagus. The esophagus is the tube that carries food and liquid to your stomach.

There are two types of esophageal cancer:

• Squamous cell carcinoma starts in the cells that line the esophagus. These cells are called squamous cells. This type of cancer can occur anywhere in the esophagus.
• Adenocarcinoma starts in the lower portion of the esophagus, near the opening to the stomach. It begins when squamous cells are replaced by glandular cells that then begin growing abnormally.

Risk factors

No one knows for sure what causes esophageal cancer. However, the most significant risk factors include the following:

• Tobacco use — The longer you smoke and the more you smoke each day, the greater your risk. Patients who develop esophageal cancer may also be at risk for developing other cancers of the head and neck.
• Alcohol consumption — Chronic or excessive consumption of alcohol, especially when combined with tobacco use, increases the risk. Consumption of hard liquor, rather than beer and wine, may increase risk even more. However, the amount consumed is the biggest factor, not the type of alcohol.
• Gastroesophageal reflux disease (GERD) — The lining of the stomach contains glandular cells that release acids and enzymes to digest food. Sometimes, these chemicals escape from the stomach and move into the esophagus. This is called reflux or GERD. One symptom of GERD is chronic heartburn.
• Barrett's esophagus — GERD is believed to irritate squamous cells near the stomach causing them to become glandular cells. This condition is called Barrett's esophagus. Glandular cells are more likely to become cancerous than squamous cells. Barrett's esophagus is the strongest risk factor for esophageal adenocarcinoma. (Squamous cell carcinoma was once the most common type of esophageal cancer. It has been surpassed by adenocarcinomas because of the growing number of cases of Barrett's esophagus.)

Other risk factors include the following:

• Age — Most people who develop esophageal cancer are over 50.
• Sex — Esophageal cancer occurs three times more often in men than women.
• Race — Squamous cell esophageal cancer is more common among African Americans than whites. However, whites have a higher incidence of esophageal adenocarcinoma.
• Diet — A diet low in fruits and vegetables, as well as certain minerals and vitamins, may raise the risk of esophageal cancer.
• Chemical irritation — Damage to the esophagus (from swallowing toxic chemicals or prior radiation therapy, for example) increases esophageal cancer risk.

Symptoms of esophageal cancer

At first, esophageal cancer may not cause any symptoms. But as it progresses, it may cause:

• trouble swallowing
• feeling like food is "stuck" in the chest
• pain in the chest or between the shoulder blades
• frequent heartburn or GERD
• severe weight loss
• hoarseness or chronic cough
• vomiting.

Other conditions can cause these symptoms. But if you have any of them, see your doctor.

Diagnosing esophageal cancer

Your doctor will examine you and review your medical history. He or she probably will order chest x-rays and other diagnostic tests, too. These may include the following:

• Routine laboratory studies — Basic blood tests can help determine if you have been losing blood and whether your organs are functioning normally. These tests can help your doctor determine what other tests are needed.
• Barium swallow — This test is an x-ray of the esophagus. You drink a liquid containing barium, which coats the interior of your esophagus. It makes it easier for your doctor to see blockages or changes in the esophagus on x-rays.
• Endoscopy — The doctor inserts a thin, lighted tube called an endoscope into your esophagus. A small video camera sits at the end of the tube. With this tool, the doctor can look for problems in your esophagus. He or she can also collect tissue samples from suspicious areas for examination. You will be given a sedative or pain medicine to minimize discomfort.
• Computed tomography (CT) scan — X-ray pictures taken from different angles provide a three-dimensional view of your internal organs. Doctors can then see if you have any masses or blockages. CT scans are especially helpful in determining the extent of cancer. This information can guide treatment decisions.
• Magnetic resonance imaging (MRI) — A diagnostic technique that uses a magnetic field to produce pictures of structures inside the body. The test provides similar information as CT scanning without radiation.
• Endoscopic ultrasound — A tiny ultrasound machine sits at the end of a tube inserted into the esophagus. It creates pictures with sound waves. This test may be better than CT at determining how far cancer has grown into the esophagus, surrounding tissue, and lymph nodes. This information is especially important in choosing a treatment and planning surgery. As with endoscopy, doctors can remove bits of suspicious-looking tissue. The tissue will then be examined in a lab.
• PET scanning — A positron emission tomography, or PET, scan is an imaging technique that uses positively charged particles (radioactive positrons) to detect subtle changes in the body's metabolism and chemical activities. A PET scan provides a color-coded image of the body's function, rather than its structure. Because the metabolic activity of cancer cells differs from normal cells, PET can detect cancer that has spread to other areas of the body. This information can affect your choice of treatment.

People with esophageal squamous cell carcinoma have a higher risk of mouth, throat, lung, and stomach cancer. That's why you may also have tests with endoscopes inside the throat and lungs, as well as chest x-rays and CT scans.

Expected duration of esophageal cancer

Esophageal cancer will continue to grow until it is treated. It can spread to almost any part of the body. The chance of survival increases greatly if the disease is detected early.

Preventing esophageal cancer

While some risk factors for esophageal cancer can't be avoided, you can lower your risk of the disease:

• Don't use tobacco in any form. If you smoke or use smokeless tobacco, get the help you need to stop.
• Never eat or drink anything that may damage your digestive tract.
• If you drink alcohol, drink in moderation. Most experts recommend that women have no more than one drink a day, men no more than two.
• If you get frequent heartburn, ask your doctor how to avoid or treat it.
• If you suffer from chronic heartburn, your doctor may suggest an endoscopy to look for Barrett's esophagus. If you have this condition, some doctors recommend periodic exams to check for abnormalities before they develop into cancer.
• Eat a Mediterranean-style diet that emphasizes fruits and vegetables.

Treating esophageal cancer

After the cancer has been diagnosed, your doctor will determine how far it has advanced and assign it a stage. The stages run from 0 to IV; the higher the stage, the further the cancer has spread. For example, in stage 0, the cancer is confined to the lining of the esophagus. In stage I, the cancer has not invaded the outer muscle layer of the esophagus.

Treatment for esophageal cancer depends on the size and location of the tumor, its stage, your symptoms, and your general health. Many different treatments and combinations of treatments may be used. The most common ones are surgery, chemotherapy, and radiation therapy.

Surgically removing the tumor and surrounding tissue offers the best chance of a cure. Usually, the surgeon opens the chest or abdomen. He or she then removes, through one or two incisions, all or part of the esophagus and the nearby lymph nodes. This helps keep the cancer from spreading.

Sometimes, the upper part of the stomach is removed, too. The surgeon then uses the rest of the stomach or part of the intestine to reconnect the digestive tract, so that you can swallow. This is very intensive surgery; some patients can't tolerate it.

The surgeon may be able to modify the procedure and use minimally invasive techniques in certain patients, such as those with other serious medical conditions. Instead of one or two larger incisions, the surgeon may make several smaller ones. This may decrease the risk of some complications. But a surgeon doing this procedure must be highly skilled.

Because esophageal surgery is so extensive, the least invasive approach to reduce the size of incisions is most desirable. The recovery times for this type of surgery are much better than more traditional surgical approaches.

Radiation therapy uses high-energy x-rays to kill cancer cells. The radiation may come from a machine outside the body (external radiation) or from radioactive material placed in or near the tumor (internal radiation).

Your doctor may suggest radiation therapy

• as the only treatment if the cancer is too large or the risk of surgery is too high
• after surgery, if the cancer cannot be completely removed
• before surgery, to shrink the tumor and make it easier for the surgeon to remove it.

Chemotherapy involves the use of anticancer drugs to kill cancer cells. The drugs are usually injected into a vein. Chemotherapy may be combined with radiation therapy.

Before recommending a treatment, your doctors will weigh the benefits of surgery against its risks. (It can cause numerous complications.) For many people, radiation therapy alone or combined with chemotherapy may offer the same chance of survival as surgery.

Some types of esophageal cancer cells contain specific mutations (changes in the DNA) that may respond to drugs that attack these mutations. This type of cancer treatment is often referred to as targeted therapy. Targeted therapy is especially relevant for cancers that occur in the lowest portion of the esophagus (just above the stomach).

Immunotherapy that helps the immune system better attack esophageal cancer cells may be considered for advanced stages not responsive to other therapies.

Your doctor may recommend other treatments to ease symptoms. For example, he or she may put a stent (a small, wire-mesh tube) in your esophagus so the cancer doesn't block it. This is generally done when the patient is spitting up food or the food is unable to go through the esophagus to get to the stomach.

This will allow you to eat normally. A laser can prevent blockages and improve swallowing by reducing the size of a tumor.

If swallowing is so difficult that adequate nutrition cannot be taken by mouth, your doctor may suggest a feeding tube inserted into the stomach or intestine.

When to call a professional

See your doctor if you have any of these symptoms:

• persistent trouble swallowing
• significant weight loss
• a feeling that food is stuck in your chest
• recurrent or persistent vomiting.

Most often these symptoms will not be caused by esophageal cancer, but they always require medical attention.

If you have been diagnosed with GERD, consult a gastroenterologist. He or she can determine whether you have any precancerous conditions in the lower esophagus — and treat them. More and more specialists ablate Barrett's esophagus with an endoscope before it becomes cancerous.

Prognosis

The earlier the cancer is detected, the higher the survival rate. Over 80% of patients diagnosed with stage 0 and stage 1 esophageal cancer live at least five years. But many cases of esophageal cancer are diagnosed at more advanced stages.

With or without surgery, chemotherapy and radiation therapy can help improve quality of life. They can also prolong survival, even when the disease is advanced.

Additional info

National Cancer Institute (NCI)
https://www.nci.nih.gov/

American Cancer Society (ACS)
https://www.cancer.org/

American Gastroenterological Association
https://www.gastro.org/