Esophageal Cancer

The oesophagus is a muscular tube that connects the mouth to the stomach and helps in the transport of food to the stomach. The oesophagus is made up of several layers of muscles that contract and help in the movement of food down the tube and into the stomach.

Oesophageal cancer occurs when the normal cells in the oesophagus turn into abnormal cells and grow out of control in the existing tissue. Over time, they form a mass called a tumour.

Depending on the type of cell lines affected, oesophageal cancer is divided into:

• Squamous cell carcinoma (SCC): squamous cells constitute the inner lining of the oesophagus. Abnormal growth of these cells leads to SCC. This type of cancer is more common in the upper parts of the oesophagus, closer to the mouth.
• Adenocarcinoma: This type of cancer arises from the abnormal growth of the mucous glands of the oesophagus. The mucous glands are responsible for the secretion of mucous which makes it smoother for the food to pass through the tube. This cancer is the most common type and often develops in the part of the tube closer to the stomach.
  • Others: these include the rarer types of oesophageal cancer such as small cell carcinoma, sarcoma, lymphoma, melanoma and choriocarcinoma

Symptoms of oesophageal cancer do not present in its early stages. As the tumour grows, symptoms appear. The symptoms include:

• Dysphagia: difficulty in swallowing. This is the earliest symptom that is seen and slowly progresses as the cancer grows.
• Unexpected weight loss.
• Chest pain associated with burning.
• Worsening indigestion or heartburn.
• Persistent cough or hoarseness of voice.
  
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As the disease progresses, it may lead to the development of complications such as:

• Complete obstruction of the oesophagus, making it impossible for food and liquids to reach the stomach
• Pain
• Bleeding into the oesophagus that can present in vomiting of blood
• Infiltration into the surrounding structures, such as the windpipe and vocal cords, hindering breathing and speech respectively

It is to be noted that by the time the symptoms are noticeable, the disease is already in the advanced stage.

The exact cause of oesophageal cancer is not known. However, many predisposing factors have been identified that have a risk of developing this cancer. These include:

• Age: oesophageal cancer is more often seen in elderly individuals (older than 60 years)
• Gender: the risk of men developing oesophageal cancer is three times more than women
• Ethnicity: it is seen that SCC is more common in African Americans and Asians whereas adenocarcinoma is more common in whites
• Consumption of tobacco and heavy consumption of alcohol lead to an increased risk of oesophageal cancer
• Gastrooesophageal Reflux Disease (GERD): a condition in which acid from the stomach repeatedly enters the oesophagus resulting in damage to the tissue. This leads to the development of a condition known as Barrett’s Oesophagus (the lining of the normal oesophagus transitions to that of the stomach lining) which increases the risk of cancer. The patient complains of recurrent episodes of heartburn
• HPV infection: infection from the Human Papilloma Virus increases the risk of SCC of the oesophagus.
• Occupational exposure: individuals exposed to dry cleaning solvents for a long time are more prone to developing this cancer.
• History of previous head and neck cancer or ongoing radiation treatment can increase the chances of developing oesophageal cancer
• Other conditions: Certain conditions such as Achalasia (a disorder involving dysfunction of the lower oesophageal sphincter), Tylosis (a rare genetic disorder involving excess skin growth) and Plummer-Vinson Syndrome are conditions that increase the risk of carcinoma in the oesophagus.

It is difficult to prevent oesophageal cancer since genetic mutations cannot be predicted easily. However, certain general measures can be taken to help reduce the risk of oesophageal cancer. These include:

• Reduce the consumption of tobacco
• Drink alcohol in moderation or stop completely
• Eat more fruits and vegetables which help boost the immune system
• Seek treatment for acid reflux and heartburn

The diagnosis is made usually by a GIT specialist (gastroenterologist). It involves taking the patient’s history, a physical examination of the patient and conducting certain investigations.

History taking

This involves asking the patient about the onset of symptoms, progression, and any associated aggravating factors or symptoms. A history of predisposing factors such as alcohol and tobacco consumption is also noted. history of other medical conditions mentioned above will also be asked

Examination

A general physical examination of the patient will be done. The general appearance of the patient will be noted. A cancer patient usually looks anaemic and malnourished. The patient's ability to swallow liquids and solids will be assessed. Lymph nodes of the neck will be palpated and examined to see the extent of the spread of cancer.

Investigations

An array of investigations are to be done to identify the type of cancer, its location and whether it has spread to other areas of the body. The investigations include:

• Complete blood count (CBC): the blood picture shows a decrease in haemoglobin, indicating anaemia.
• Endoscopy: in this technique, a flexible tube is inserted through the mouth into the oesophagus. A camera is attached to the end of the tube which helps to identify abnormal lesions or growth in the oesophagus. A biopsy (sample of the tissue) is taken and sent for pathological examination. This confirms the type of oesophageal malignancy.
• Certain radiological investigations can be done. These include:
  • MRI scan and CT scan: it helps evaluate the spread of the tumour to the chest and the abdomen.
  • Barium Swallow X-ray: in this procedure, a special radio-opaque liquid is swallowed and dynamic X-rays are taken. The X-rays show the location of the tumour in the oesophagus.
  • PET scan: it is a scan done to see if the tumour has spread to other organs and lymph nodes.

Radiological investigations help distinguish the stage of cancer. Staging of the tumour is important to determine the course of treatment since different stages have different approaches to treatment.

The combined approach of history taking, examination of the patient and the results from the imaging studies and biopsy help confirm the type of oesophageal cancer and its staging.

Treatment of oesophageal cancer depends on the stage of cancer. Various treatment approaches are present which may be used in combination at times to ensure better efficiency of treatment, depending on the type and stage of cancer and the patient's ability to tolerate the said treatments.

The treatment options are:

• Surgery: Surgery can be used alone or in a combination with other treatments. The surgeries can be targeted towards  the removal of
  • Very small tumours from the oesophagus: this uses an endoscopic approach
  • The section of the diseased oesophagus (esophagectomy)
  • A part of the oesophagus along with the upper part of the stomach (oesophagogastrectomy)
  In the last two surgeries, the affected lymph nodes are also removed. Surgery carries a serious risk of complications, such as infection, bleeding and leakage of food from the area of surgery. Surgery often is an open procedure and the patient takes a prolonged time to recover.
• Chemotherapy: this approach uses certain drugs that target cancer cells. Chemotherapy drugs are used before (neoadjuvant) or after (adjuvant) surgery. They can also be used in combination with radiation therapy. In the advanced stages of the disease, these drugs help reduce signs and symptoms caused by cancer.
• Radiation therapy: this technique uses high-energy radiation targeted at the tumour which destroys the cancer cells. Radiation therapy is specifically used when the tumour is obstructing swallowing.
• Combined therapy: it combines both chemotherapy and radiation and, hence, provides a synergistic effect in the treatment.
• Targeted drug therapy: this is a group of drugs that target the specific weakness of the cancer cells, thereby forcing them to die. They can be used in combination with chemotherapy for advanced cancers or when the cancer is not responding to other treatments.
• Immunotherapy: this mode of treatment is focused on enhancing the individual's immune system. The drugs aim at helping to identify the cancer cells and assist in fighting against the disease. Immunotherapy is useful in advanced cancer which has spread, or if cancer has returned after treatment (remission).

People with oesophageal cancer may also participate in clinical trials. Clinical trials are research programs conducted with patients to evaluate new methods of treatment.

Apart from specific treatment for cancer, the patient and their families are advised to undergo counselling sessions. Such sessions are important because cancer is a very worrisome disease and methods of coping and support are taught in these sessions.

The survival chance of an individual with oesophageal cancer depends on the stage of cancer and the person’s general health. In the early stages, cancer can be managed successfully. Unfortunately, the cancer is often diagnosed in the later stages and then the prognosis is often poor. It is estimated in general that the five-year survival rate of this cancer is 19.2%.

Oesophageal cancer is a notorious disease. Commonly seen in elderly males, the symptoms are often discovered in the advanced stage of the disease. Various types of treatments are available (sometimes in combination) to help fight the disease; each treatment regimen depends on the patient's health and the type and stage of cancer. However, since the disease is often diagnosed in the advanced stages, treatment is difficult. Psychological support and coping methods are extremely important, especially in the advanced stages of the disease.