Overview
Cancer of the oesophagus is relatively rare in Europe but has become more common over the last 30 years. Approximately 45,000 new cases are diagnosed each year across Europe (which is about 2% of all new cancer cases). It mainly affects people over the age of 50. There are virtually no cases in people under the age of 45.
There are two distinct types of oesophageal cancer:
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Key Figures
| Total number of new cancer cases in Europe (2006) |
3.2 million |
| Total number of cancer deaths in Europe (2006) |
1.7 million |
| Number of new oesophageal cancer cases (2006) |
45,000 |
|
(34,300 men) |
|
(11,700 women) |
| Number of oesophageal cancer deaths (2006) |
38,500 |
|
(29,300 men) |
|
(9,200 women) |
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Cancer Types
There are two different types of cancer that start in the oesophagus:
Because the two cancers have different causes and treatments a separate section has been written for each type.
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Squamous Cell Cancer of the Oesophagus
Causes of Squamous Cell Cancer of the Oesophagus
The main risk factors for developing squamous cell cancer of the oesophagus for people in Europe are smoking and alcohol.
People who both drink and smoke greatly increase their chances of developing oesophageal cancer statistically.
Poor diets that are lacking in zinc and other essential vitamins and minerals increase the risk of developing oesophageal cancer. In addition, drinking very hot (burning hot) drinks and eating meat which has been cooked at very high temperatures, such as on a barbecue are known risk factors.
Prevention of Squamous Cell Oesophageal Cancer
The guidance for reducing the risk of developing this cancer is to stop smoking, to drink alcohol in moderation and to avoid eating meat that has been cooked at very high temperatures.
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Adenocarcinoma of the Oesophagus
Causes of Adenocarcinoma of the Oesophagus
People who are more than 25% overweight have a higher risk of developing adenocarcinoma of the lower part of the oesophagus. Reflux of acidic stomach contents causes inflammation and cell damage which can lead to Barrett’s oesophagus. This in turn can develop into an adenocarcinoma. Barrett’s oesophagus is a pre-malignant condition.
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Barrett's Oesophagus
This condition was first described in 1950. Barrett's oesophagus occurs when the stomach contents, including bile and stomach acid, reflux into the oesophagus.
10% of patients with gastro-oesophageal reflux develop Barrett's oesophagus and of these 1% per year develop adenocarcinoma. Overall Barrett's oesophagus increases the risk of developing this cancer by 30 times.
Barrett's oesophagus is not associated with any specific symptoms and is usually discovered accidentally during other investigations.
Patients with Barrett’s oesophagus are treated with life-long acid suppression. Anti-reflux surgery may be advised in some cases to reduce the chances of progression to cancer.
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Common Symptoms
The classic symptoms of oesophageal cancer are:
- difficulty in swallowing – firstly with solids then with softer foods and liquids
- indigestion associated with acid reflux from the stomach
- unexplained weight loss
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Diagnostic Tests
The diagnosis is usually confirmed by direct examination of the oesophagus by oesophagoscopy and biopsy. CT, MRI and PET scanning are useful in determining the extent of the disease and response to treatment.
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Treatment for Oesophageal Cancers
Treatment of Squamous Cell Cancer of the Oesophagus
Treatment for squamous cell cancer of the oesophagus is either surgery, radiotherapy and chemotherapy (chemoradiation) or a combination of the two (i.e surgery and chemoradiation).
Surgery
In younger patients with squamous cell cancer of the oesophagus, removing the cancer by surgery is one option. This is a major operation which involves removing part of the oesophagus through an incision in both the chest and abdomen and then linking the remaining part of the upper oesophagus to the stomach.
Surgery carries persistent post-operative side effects and a significant mortality rate of up to 5% (even in the best centres).
Specialist centres usually use pre-operative chemoradiation which improves the results of surgery.
However, surgery is not an option for all patients. If the cancer has spread outside the oesophagus or if the patient is not a good operative risk, a combination of radiotherapy and chemotherapy may be more effective.
Chemoradiation
The alternative to surgery is a combination of chemotherapy and radiotherapy (chemoradiation).
Treatment is carefully planned by a team of health professionals to suit the needs of each individual patient. The team will include doctors, physicians, radiographers, technicians and nurses all of whom have special training in radiotherapy and the treatment of cancers.
Side effects of chemoradiation
Radiotherapy and chemotherapy cause a number of side effects, but most of these side effects improve rapidly after treatment has finished and can be treated symptomatically during treatment.
General side effects include feeling sick and tired. Because the radiotherapy is focused on the oesophagus, the lining becomes inflamed causing some soreness when swallowing, which can seem to make things worse rather than better. However, this does improve over time and some symptomatic treatments are available while it persists.
If radiotherapy is given towards the top end of the oesophagus, the mouth may also be affected. Reduced amounts of saliva can make the mouth dry. This is usually a temporary side effect but occasionally it can last for some time.
Chemotherapy can make patients more vulnerable to infections. Hair loss is another potential problem, but the hair does grow back after treatment has finished.
Treatment of Adenocarcinoma of the Oesophagus
Adenocarcinoma of the oesophagus is a difficult disease to treat as it tends to metastasise early.
If there is no evidence that the cancer has spread and there are no other reasons to avoid surgery, chemotherapy followed by surgery is likely to be the best option. In some centres, the effect of a course of chemotherapy is assessed using a sophisticated scan (PET scan). Patients with a good response benefit more from surgery.
Adenocarcinomas do not respond well to radiotherapy so this is not used in their treatment.
Post operative chemotherapy (combinations of epirubicin, cisplatin and 5FU, or mitomycin, cisplatin and 5FU) is used as adjuvant therapy.
Chemotherapy with these drugs can cause tiredness and vulnerability to infections. Nausea and sickness are common side effects which normally disappear soon after treatment ends and can be controlled by medication while they last. Hair loss is another potential problem but the hair does grow back after treatment has finished.
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Prognosis
Many factors affect prognosis, including the stage of the cancer, the patient’s age, general health and their individual response to treatment (which will vary).
For this reason, statistics can only be considered as a general guide as they are produced by grouping together patients in whom these factors are similar but not identical. These figures are historical, often covering a 10 or 20 year period, and so do not reflect improvements in survival through more modern treatment.
Survival rates indicate the percentage of people who survive the disease for a specific period of time after their diagnosis – usually 5 or 10 years.
The prognosis of oesophageal cancer is poor in patients who present with an advanced stage of the disease:
- The overall five year survival rate is less than 5%.
- For cancer confined to the oesophageal mucosa the 5 year survival rate is about 80%.
- Cancers with submucosal involvement have a 5 year survival rate of less than 50%.
- Cancers extending into the muscular layer of the oesophageal wall have a 5 year survival rate of 20%.
- Cancers extending to adjacent structures have a 5 year survival rate of less than 10%.
- Cancers with distant metastases have a 5 year survival rate of less than 3%.
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Key Trends
- Results of treatment are significantly better in specialist centres.
- Continuing research into the best combination of treatments, and the best doses of these treatments is a key research area.
- Scanning to determine which patients will respond well to treatment is being developed in some centres.
- Monoclonal antibodies may be useful in the treatment of squamous cell cancers but not in the treatment of adenocarcinomas.
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