Cancer of the Oesophagus
Cancer of the oesophagus develops from the lining of the gullet and narrows the oesophagus, which makes it hard for you to swallow food and even liquid.
The cancer tends to be of two main types. One type is adenocarcinoma which tends to appear in the lower oesophagus at the junction with the stomach. This type is thought to be linked to Barrett’s, even if this has not already been diagnosed. The other type is squamous cell carcinoma which tends to affect the upper part of the oesophagus and is more strongly linked with smoking. Squamous cancer is very common in some parts of Africa and China, and is likely to be partly caused by the local diet or the way that food is kept and cooked.
Because the oesophagus is a muscular tube it is quite stretchy so you may not find it hard to swallow until the cancer is quite large. By this time the cancerous cells may have spread outside the gullet to lymph nodes (internal glands) and blood vessels in your chest, and may also be in your bloodstream where they can form secondary tumours (metastases) in the liver or elsewhere.
Most patients are first diagnosed with squamous cancer or adenocarcinoma when they need medical attention because they find it hard to swallow (dysphagia) and they have lost weight. Going to your doctor early when symptoms first start is important to increase the chances of diagnosing and treating the cancer. Investigations are very important to make a diagnosis. The best test is normally an endoscopy although your doctor may decide a barium swallow is a better option.
During an endoscopy the cancer may be easy to see but it is very important a biopsy is taken to confirm the diagnosis. To find out how advanced the cancer is other tests will include a CT scan (a type of X-ray examination) and often a test called a PET scan. An ultrasound machine called an endoscopic ultrasound can be attached to the end of the endoscope to look in detail at the layers of the oesophagus. If the tumour is in your stomach then a surgeon may have to look inside your abdomen using a special illuminated tube (laparoscopy). Although these tests may take some time they are very important to help the specialist team decide on the best kind of treatment.
Surgery is the most common treatment for this in the United Kingdom, particularly if the cancer has not spread outside your oesophagus. Depending on the position of the tumour the surgeon may need to enter your chest cavity, the abdomen or the neck, and will remove the affected part of the oesophagus and the surrounding lymph glands. They will then make a tube out of the stomach, which is drawn up into the chest or neck where they will join it to the remainder of the oesophagus. Advances in surgery mean that this can now sometimes be done as a keyhole (laparoscopic) operation in specialist centres. However it is carried out this is a big operation. You will usually be cared for in an intensive-care or high-dependency ward .After leaving hospital you can eat normally, although you may feel full very quickly. Things should get back to normal over the following months.
Sometimes, to increase the chances of getting rid of all the cancer cells, chemotherapy is used with surgery. Because chemotherapy travels in the blood stream it can remove any cancer cells, even those not attached to the main cancer. Chemotherapy is usually given before surgery and sometimes afterwards as well. Radiotherapy can also be used with surgery and is particularly useful for squamous cell cancers which are more sensitive to X-ray treatments. You may have chemotherapy and radiotherapy together followed by surgery (called triple modality therapy).
When the cancer is too advanced to be cured there are ways of easing symptoms and prolonging life through ‘palliative’ therapies. These may include radiotherapy, usually in small doses, or chemotherapy. Radiotherapy can be given as an external beam or on the inside of the gullet through an endoscope (brachytherapy). A stent may be used to open up your oesophagus, and this is usually done under heavy sedation in the endoscopy department. This can help swallowing and may help you regain weight. Sometimes laser therapy can achieve a similar effect.
Research is still being carried out to find out what the best types of treatment are. There are also treatments that take the molecular type of cancer into account, like the Herceptin treatment for breast cancer. Your specialist will decide exactly which type of treatment you need and it will be some time before it is known which patients benefit most from these different kinds of treatment.