Esophageal Cancer (Oesophageal Cancer)

What is Esophageal Cancer?

Esophageal (or Oesophageal) problems often present with symptoms. These symptoms typically include mild difficulty swallowing to the complete inability to swallow. Other symptoms may include painful swallowing, perception of worsening reflux and weight loss. A long history of reflux followed by swallowing difficulties is a major concern and requires careful assessment.

Making the diagnosis

A proportion of oesophageal problems are incidentally picked up at gastroscopy. Sometimes these are picked up when patients are on a surveillance programme (eg. for Barrett’s). In this group of patients, they do not usually have symptoms.

Esophageal Cancers

The two common types of oesophageal cancers are squamous cell and adenocarcinoma. Squamous cell cancers of the oesophagus are associated with smoking and alcohol. Squamous cell cancers typically manifest in the proximal (higher up) to mid oesophagus. The diagnosis is usually made on appearance, location and biopsies. As this cancer has a different biological behavior, the treatment can be quite different. Radiotherapy is frequently used in conjunction with chemotherapy. Combination of the two therapies with surgery is another option but would need further discussion with your surgeon. Adenocarcinoma of the oesophagus typically occurs in the lower oesophagus. There are contributory factors such as long-term reflux, obesity, alcohol and smoking. Long-term reflux leads to formation of Barrett’s oesophagus.

What now that I have Esophageal Cancer?

Staging the tumor

When the diagnosis is confirmed, the next step is to “stage” the tumor. This “staging” process essentially tells the surgeon, the location, the severity and the extent (ie. its spread). This may take the form of a repeat gastroscopy, CT-scans, PET-scans and possibly laparoscopy. Sometimes an endoscopic ultrasound (EUS) may aid with staging of an early cancer. With all the available information, treatment can be discussed and planned.

Fitness assessment

Tests to evaluate the function of the heart and lungs may be requested as part of treatment planning by the surgeon, anaesthetist or involved physician.

Multidisciplinary Assessment

Your case will be discussed by a multidisciplinary team of specialists in oesophageal cancer who will be involved in your care including surgeons, oncologists, radiotherapists, cancer care nurses, radiologists, nuclear medicine physicians, pathologists and dietitians to achieve consensus on treatment approach. The outcome of these meetings will be discussed in detail with you and you will see the various specialists as required. Often, a care co-ordinator or other support person will be intimately involved in helping guide you through this process.

Treatment for Esophageal Cancer

Treatment modalities include:

• Chemotherapy
• Radiotherapy
• Surgery

In various combinations depending on the “stage” of the cancer – hence the vital importance of the staging process. Surgery is of no benefit if the cancer has reached a stage where it has spread to organs beyond the oesophagus such as the liver or lungs. Similarly if the cancer had reached a stage where the chance of cure was negligible, generally surgery would not be undertaken since it is a very major operation with prolonged recovery and high risk and likely to be of little benefit. There are other surgical treatments (such as oesophageal stents) that can provide good relief without affecting survival. These stents work similarly to the cardiac stents. It keeps the blockage open, allowing passage of fluid and pureed food to pass with relative ease.

Treatment of Adenocarcinoma Oesophagus

When thought to be potentially curable after appropriate staging, the commonest sequence of treatment is chemotherapy (3 months) then surgery followed by further chemotherapy. Sometimes radiotherapy may be added for large tumors before surgery. Small or early tumors may be treated by surgery alone.

Treatment of Squamous cell cancer Oesophagus

This type of cancer is quite sensitive to radiotherapy and chemotherapy in combination and this may be used as stand alone treatment without surgery. Surgery may be used, particularly with tumours in the lower part of the oesophagus. In this setting chemotherapy or chemoradiotherapy would take place prior to surgery. Small or early tumors may be treated with surgery alone.

What should I do before an oesophageal operation?

Most often, patients would have undertaken a few cycles of chemotherapy with or without radiotherapy. There is a period of convalescence prior to surgery. It is highly desirable that nutrition and fitness be at the patient’s best, even before any treatment has taken place. Sometimes optimal nutrition is not achievable and we would consider a temporary avenue of feeding. Keeping up physically is very important, as the body will undergo a series of large insults from different treatment. The easiest way to achieve this is to give up smoking completely (if one smokes). Additional and frequent gentle exercises such as 10minute walks, walking up and down the stairs and household activities are strongly encouraged. In general, the fitter the patient is before an operation, the better the outcome.