Introduction
Oesophageal cancer 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:
Back to top
The Oesophagus
In effect, the oesophagus is a tube which links the throat to the stomach. At its lower end is a valve which stops the acid contents of the stomach flowing back into the oesophagus (acid reflux) and damaging the lining. Acid reflux can cause inflammation of the oesophagus and is associated with a condition called Barrett’s Oesophagus which can develop into oesophageal cancer.
The cells lining the upper two thirds of the oesophagus are similar to skin cells. They are flat and form several layers with the top, or inside layer, constantly being shed. In the lower third of the oesophagus, the cells are more like those in the rest of the digestive system, containing numerous mucus glands that produce a slimy substance which helps food slide down the oesophagus more easily.
Back to top
Cancer of the Oesophagus
All cancers are uncontrolled growths of cells. In oesophageal cancer, this uncontrolled growth happens in the cells lining the oesophagus.
One of the characteristics of cancer is that it can spread to other parts of the body either by direct invasion of neighbouring areas or because cancer cells travel through the blood or lymphatic system to other parts of the body. Oesophageal cancer may spread to surrounding structures in the chest such as the lungs and the trachea (windpipe) as well as through the bloodstream to the liver and bones.
There are two different types of cancer that start in the oesophagus. Squamous cell cancers develop in the upper two thirds of the oesophagus. Adenocarcinomas develop in the lower third of the oesophagus and are often now referred to as Barrett’s carcinoma. The two cancers have different causes and treatment.
Back to top
Oesophageal Cancer Risk Factors
A risk factor is something that increases the chance of developing a cancer.
Squamous Cell Cancer of the Oesophagus Risk Factors
The main risk factors for developing squamous cell cancer of the oesophagus for people in Europe are smoking and alcohol.
Tobacco smoke (especially cigarette smoke) contains nitrosamines which increase the risk of cancer. These chemicals come into direct contact with the oesophagus when tobacco smoke is swallowed (which inevitably happens when smoking).
Alcohol also increases the risk of oesophageal cancer. Those who both drink and smoke increase their chances of developing oesophageal cancer statistically much more than just adding these two individual risk factors together.
As with many cancers, diet affects the risk of developing oesophageal cancer. Poor diets lacking zinc and other essential vitamins and minerals increase the risk as does drinking very hot (burning hot) drinks and eating meat which has been cooked at very high temperatures, such as on a barbecue.
A diet that is high in fresh fruit and vegetables, by contrast, reduces the risk of oesophageal cancer, possibly because the antioxidant vitamins A, C and E prevent damage to the lining of the oesophagus. Selenium found in fresh fruit and vegetables, meat and eggs, also has a protective effect.
Adenocarcinoma of the Oesophagus Risk Factors
People who are more than 25% overweight have a higher risk of developing cancer of the lower part of the oesophagus. This is linked to the acid contents of the stomach flowing back into the oesophagus - in obese people the valve at the bottom of the oesophagus, which should prevent this happening, fails to function properly. The acid stomach contents cause inflammation and cell damage which can cause changes leading to Barrett’s oesophagus, which can, in turn, develop into the less common form of oesophageal cancer – adenocarcinoma. Barrett’s oesophagus, therefore, is referred to as a pre-malignant or pre-cancerous condition.
Back to top
Barrett's Oesophagus
This condition was first described in 1950 as a change in the lining of the lower part of the oesophagus. This can progress over time into an adenocarcinoma. Barrett's oesophagus occurs when the stomach contents, including bile and stomach acid, reflux into the oesophagus.
10% of patients with gastro-oesophageal reflux are affected by Barrett's oesophagus, and of these 1% per year develop a carcinoma. Overall, Barrett's oesophagus increases the risk of cancer by 30 times.
Barrett's oesophagus does not produce any symptoms in itself 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.
Back to top
Preventing Oesophageal Cancer
Preventing Squamous Cell Oesophageal Cancer
Although there is no way of completely eliminating the risk of developing oesophageal cancer, there are things which can be done to reduce the risk. Stopping smoking, drinking alcohol only in moderation and losing weight if you are more than one and a quarter times your ideal weight will all reduce known risk factors. Avoiding eating meat that has been cooked at very high temperatures also reduces the risk.
Preventing Adenocarcinoma of the Oesophagus
If you suffer from indigestion, this may be due to the acid contents of the stomach flowing back into the oesophagus. Eventually this can cause changes which can lead to cancer. Your doctor can advise you on various ways in which this can be treated, thereby reducing the risk associated with it.
A healthy balanced diet containing zinc, selenium and antioxidant vitamins A, C and E will also protect against oesophageal cancer. All these dietary elements are found in fresh fruit and vegetables and to some extent in meat and eggs.
Back to top
Symptoms of Oesophageal Cancer
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
These symptoms may be due to a variety of conditions, of which only one is oesophageal cancer. However, individuals over the age of 55 with these symptoms should seek medical advice promptly.
Back to top
Diagnosing Oesophageal Cancer
The diagnosis of oesophageal cancer is usually confirmed by an oesophagoscopy. A thin flexible fibre optic tube is passed down the oesophagus, so that the doctor can see its lining. Samples (or biopsies) of any abnormal patches can also be taken and sent to the laboratory for examination under the microscope.
Back to top
Treatment of Oesophageal Cancer
Treatment of Squamous Cell Cancer of the Oesophagus
Treatment for oesophageal cancer is either through surgery, or 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 the affected 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.
With such major surgery, there is inevitably a degree of risk and persistent post-operative side effects.
Specialist centres usually use chemotherapy and radiotherapy (see below) together before surgery as this has been shown to improve the results of surgery.
But surgery is not an option for all patients as it involves a major operation and if the disease may have spread outside the oesophagus, 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, medical physicists, radiographers, technicians and nurses all of whom have special training in radiotherapy and the treatment of cancers.
Radiotherapy does cause a number of side effects. Some of these are general effects such as feeling sick and tired. Because the radiotherapy is focused on the oesophagus, its lining becomes inflamed causing some soreness when swallowing. This may appear to be making things worse rather than better. However, there are medications available to ease these symptoms which will improve over time.
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 sometimes it can last for some time.
Chemotherapy can cause a number of side effects, but does not affect everyone in the same way. Chemotherapy can make you feel tired and be more vulnerable to infections. Nausea and sickness are common side effects which normally disappear soon after treatment ends and are usually well controlled by medication.
Treatment of Adenocarcinoma of the Oesophagus
Adenocarcinoma of the oesophagus is a difficult disease to treat as it can spread to other areas of the body at an early stage. 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 will benefit more from treatment with surgery.
Adenocarcinomas do not respond well to radiotherapy so this is not often used in the treatment of these tumours.
Chemotherapy is also used after surgery to destroy cancer cells that have not been removed during surgery or as an alternative to surgery. The drugs commonly used are combinations of epirubicin, cisplatin and 5FU, or mitomycin, cisplatin and 5FU.
These drugs can cause a number of side effects, but do not affect everyone in the same way. They can make you feel tired and more vulnerable to infections. Nausea and sickness are common side effects which normally disappear soon after treatment ends and can normally be well controlled by medication.
Back to top
Looking after Yourself
Radiotherapy is highly effective as part of the treatment of many forms of oesophageal cancer, but all treatments can cause some side effects. Some patients will not experience any severe side effects, whilst others may find several troublesome. Fortunately, many of these side effects disappear soon after the treatment ends and the symptoms can usually be treated, so if you do experience any problems it is important to mention them to your doctor or nurse, so they can give you the treatment you need.
Some inflammation of the oesophagus is inevitable, with soreness and some difficulty in swallowing. Soluble aspirin and mucaine will help with these symptoms.
Some foods will be easier to swallow than others, and for some people, liquidised foods and high calorie and high protein supplements are the best way to ensure that all necessary nutrients are included in the diet. There are also exercises to try, if you find swallowing difficult.
Some patients may be troubled with a fungal infection with candida (sometimes known as thrush). This forms white patches which are sore, but treatment is effective and quickly resolves the problem.
Whatever the problem, do not assume that nothing can be done about it – ask your doctor or nurse: do not just grin and bear it.
Back to top
Questions for your Doctor
Before making up your mind about the best treatment option for you, you will need information about your cancer, the treatments available in your area and what they will involve, what to expect from the treatment, what side effects you might experience and how these may change over time as well as what your doctors believe would be most effective in combating your cancer.
For different patients the answers will be different, so it is important to discuss all these issues with your doctor so that you are able to make the right choice for you.
You will have your own questions but some issues you might want to raise are:
- What does the treatment involve?
- What are the benefits I might get?
- How good are my chances of getting those benefits?
- Could having treatment make me feel worse? If so, in what way?
- Are there alternative treatments?
- What are the risks of the treatment?
- Are the risks minor or serious? How likely are they to happen?
- What care will I need after treatment?
- What happens if something goes wrong?
- What may happen if I don’t have the treatment?
Back to top
Conclusion
There is no one solution to the management of oesophageal cancer, but for clinical and personal reasons particular treatments will suit some patients better than others. Patients, therefore, need comprehensive information so that they are able to make the right decision for them.
Back to top