CANCER OF THE OESOPHAGUS

by Digestive Disorders Foundation

What is the Oesophagus?

The oesophagus (gullet) is the tube through which food and drink pass from the back of the throat to the stomach. It lies in the back of the chest just in front of the spine. The outer muscular layers of the oesophagus move fluid or food towards the stomach. At the lower end there is a muscular valve which prevents stomach acid from entering the gullet from below.

Cancer of the oesophagus

The cancer arises from the lining of the gullet and the effect is to narrow the oesophagus and cause difficulty in swallowing. First solid food tends to lodge or stick and then liquids. The cancerous cells may also spread outside the gullet to involve the neighbouring structures, such as lymph nodes and blood vessels in the chest, and they may be carried in the blood stream to form secondary tumours in the liver or elsewhere.

Most cancers in the upper two-thirds of the gullet are known as squamous carcinomas from the squamous (skin-like) cells which line the oesophagus. Those occurring near the join with the stomach, are usually adenocarcinomas, derived from stomach-like cells. This is particularly the case when stomach-type (columnar) cells have replaced squamous cells at the lower end of the gullet, a condition known as Barrett’s Oesophagus.

What causes cancer of the oesophagus?

This cancer is particularly common in some parts of Africa and China and is probably related to local diet or the way food is cooked. In the West, important risk factors are cigarette smoking and alcohol consumption. A combination of the two appears to increase the risk. Severe acid reflux from the stomach seems to be a major factor in a recent increase in the number of people with adenocarcinomas.

A rare muscular disorder, achalasia, a condition in which there is a failure of relaxation of the muscular valve at the lower end of the gullet, very occasionally leads to cancer.

What are the symptoms?

There is a progressive difficulty in swallowing, initially for solids such as meat, and then for softer foods. Eventually there is difficulty getting liquids down. Patients lose weight and may have other symptoms such as coughing, choking, unexplained chest infections or a hoarse voice.

How is the diagnosis made?

Going to the doctor early when symptoms arise is essential, particularly if there is a progressive deterioration in the ability to swallow. Urgent referral to an appropriate specialist is then necessary and a barium swallow is often carried out. This involves swallowing a white liquid containing barium, which shows up on X-ray, outlining the oesophagus and revealing the level of obstruction. Another test is to pass a narrow flexible telescope (endoscope) into the gullet via the mouth. This test is done using an anaesthetic throat spray and/or a sedative injection. Any change in the lining of the gullet can be seen and samples taken (biopsy) for laboratory examination.

If cancer is diagnosed, other tests may be done to see how extensive it is. These include an X-ray of the chest, an ultra-sound investigation which can be done via the skin, or using an endosocope. Other possible tests include a CT scan or magnetic resonance imaging (MRI). A surgeon may also look inside the abdomen using a special tube called a laparoscope.

Treatment

Surgery is the most commonly used treatment in the United Kingdom, particularly if the cancer has not spread beyond the oesophagus. Depending on the position of the tumour, the surgeon may need to enter the chest cavity, the abdomen or the neck and will remove the affected part of the oesophagus with the surrounding lymph glands. A tube is then made out of the stomach, which is drawn up into the chest or neck where it is joined to the remainder of the oesophagus. Patients are usually cared for in an intensive care ward after the operation. After leaving hospital, patients can eat normal foods but may feel full rather quickly. This usually improves over the next few months.

Radiotherapy is also used as a potential cure in some patients; it may be the only treatment but is sometimes used in conjunction with surgery. Even if the tumour cannot safely be removed by surgery then radiotherapy and chemotherapy can be used as a treatment. Radiotherapy can be given as an external beam or on the inside of the gullet via an endoscope (Brachytherapy).

Treatment of symptoms

If surgery is not possible, there are ways to help to relieve difficulties in swallowing.

Endoscopic intubation is usually done under sedation or anaesthetic in the endoscopy department. A tube is inserted to hold the walls of the gullet open so that food and fluid can be swallowed easily. These tubes may be made of plastic or of springy metal coils. The tubes can become blocked by large food particles so hospitals will give an instruction sheet to advise patients on their diet. Some patients are bothered by heartburn and regurgitation and this can be helped by taking acid suppressors.

Endoscopic laser treatment is also possible and a specialist endoscopist will use a laser to destroy any tumour that is growing into the gullet. In some patients, laser treatment and intubation need to be combined.

Future treatments

Major national and international trials are studying the effects of chemotherapy (or combined chemotherapy and radiotherapy) given either before or with surgery, compared to surgical treatment alone. The patient’s specialist will determine exactly which variety of treatment is needed and it will be some time before it is known which patients are benefitted by these various treatment methods.

A new approach is to use photodynamic therapy (PDT). This involves giving the patient a special chemical which enters the cancer cells and is sensitive to certain light wavelengths. When light is passed into the oesophagus using a probe, it activates the chemical, which then destroys the cancer. This is an experimental treatment that is currently being investigated.

Barrett’s Oesophagus

Barrett’s Oesophagus is a condition in which stomach-like cells form the lining of the lower oesophagus. It is often found during an endoscopy. Once the condition has been detected, repeated examinations might identify those people who develop pre-cancerous changes (dysplasia). Barrett’s surveillance programmes are being set up in a number of hospitals in the UK, but it is not clear how many dysplasias or early cancers can be diagnosed in this way. It will be some years before the advantages and disadvantages of this type of surveillance become clear and a general policy is adopted.

Summary points

Prompt consultation with a doctor is essential for patients with symptoms of food sticking in the gullet. If the disease can be identified early, then a cure is possible. Attempts to achieve a cure usually involve an operation. Where a cure is not possible, a wide variety of treatments are available for symptom relief.