Oesophageal cancer develops in the tissues lining the oesophagus, a hollow, muscular, tube-shaped organ of the digestive system, responsible for the movement of food and liquid from the mouth to the stomach.
There are two main types of Oesophageal Cancer. The first and most common type is Oesophageal adenocarcinoma, which often begins near the gastro-oesophageal junction (where the oesophagus and the stomach meet). This type of oesophageal cancer is linked to a condition called Barrett’s oesophagus, however, people without this condition can develop oesophageal adenocarcinomas. The less common type of oesophageal cancer is called oesophageal squamous cell carcinoma. This type of oesophageal cancer usually develops in the squamous cells of the upper and middle portions of the oesophagus. There are also some rarer forms of oesophageal cancer, including oesophageal small cell carcinoma, oesophageal sarcoma, oesophageal lymphoma, oesophageal melanoma and oesophageal choriocarcinoma.
Oesophageal cancers are generally diagnosed in people over 60, and is more prevalent in men. However, people of any age and any gender can develop this disease.
Treatment
If Oesophageal Cancer is detected, it will be staged and graded based on size, metastasis and how the cancer cells look under the microscope. Staging and grading helps your doctors determine the best treatment for you.
Cancers can be staged using the TNM staging system:
- T (tumour) indicates the size and depth of the tumour.
- N (nodes) indicates whether the cancer has spread to nearby lymph nodes.
- M (metastasis) indicates whether the cancer has spread to other parts of the body.
This system can also be used in combination with a numerical value, from stage 0 – IV:
- Stage 0: this stage describes cancer cells in the place of origin (or ‘in situ’) that have not spread to nearby tissue.
- Stage I: cancer cells have begun to spread to nearby tissue. It is not deeply embedded into nearby tissue and has not spread to lymph nodes. This stage is also known as early-stage cancer.
- Stage II: cancer cells have grown deeper into nearby tissue. Lymph nodes may or may not be affected. This is also known as localised cancer.
- Stage III: the cancer has become larger and has grown deeper into nearby tissue. Lymph nodes are generally affected at this stage. This is also classified as localised cancer.
- Stage IV: the cancer has spread to other tissues and organs in the body. This is also known as advanced or metastatic cancer.
Cancers can also be graded based on the rate of growth and how likely they are to spread:
- Grade I: cancer cells present as slightly abnormal and are usually slow growing. This is also known as a low-grade tumour.
- Grade II: cancer cells present as abnormal and grow faster than grade I cancers. This is also known as an intermediate-grade tumour.
- Grade III: cancer cells present as very abnormal and grow quickly. This is also known as a high-grade tumour.
Once your tumour has been staged and graded, your doctor may recommend genetic testing, which analyses your tumour DNA and can help determine which treatment has the greatest chance of success. They will then discuss the most appropriate course of treatment for you.
Treatment is dependent on several factors, including location, stage of disease and overall health.
Surgery
Surgery is the main treatment option for early-stage oesophageal cancer. Depending on the stage and location of the tumour, the doctor may perform an open surgery or an endoscopic resection, which is a minimally invasive surgical procedure, to remove the tumour. Your surgeon will remove the tumour and a healthy margin of tissue to prevent recurrence. In some instances, part or all the oesophagus and/or a portion of the upper stomach may also be removed. Your surgeon will discuss the most appropriate surgery for you, risks, and any potential complications with you prior to the commencement of treatment.
In many cases, surgery is used in conjunction with chemotherapy and radiation therapy.
Radiation therapy
Radiation therapy, or radiotherapy, uses controlled doses of radiation to damage or kill cancer cells. It can be administered internally or externally. This may be a satisfactory alternative if you are not a suitable candidate for surgery. This treatment can also be used in addition to surgery. In some cases, radiotherapy is recommended prior to surgery to shrink the tumour so it’s easier to surgically remove. It can also be recommended after surgery to reduce the risk of cancer recurrence in the future.
Chemotherapy
Chemotherapy uses drugs to kill or slow the growth of cancerous cells, while minimising the damage to healthy cells. It is usually administered directly to the veins (intravenously), however in some cases in can be administered orally. You may receive a single chemotherapy drug, or a combination, depending on your individual factors. It is usually done in cycles of treatment sessions and periods of rest and can last several months. Chemotherapy can be recommended for patients prior to surgery in order to shrink the tumour, making it easier to surgically remove. In some cases, it can also be recommended after surgery to reduce the risk of cancer recurrence, or if your tumour is advanced and has metastasised.
Clinical trials
Clinical trials are research studies performed to test new treatments. They present the opportunity for people, particularly those with rare or complex cancers, to receive very new treatments which are not yet available otherwise. While these studies have the potential to develop more treatment options, the risk of side effects can be high and are not always known. These trials might involve targeted therapies (to target only the cancer cells), hormonal therapies or immunotherapies.
Clinical trials are often conducted in phases:
- Phase 0: these trials are used to determine how the body will react to experimental drugs. They are given in very small doses in very few people.
- Phase I: these trials are used in slightly bigger groups (20-80 people) to determine the safety of the drug, as well as any potential side effects that may arise.
- Phase II: these trials are used in larger groups (several hundred people) to further evaluate the safety of the drug, as well as whether it is working as it should be.
- Phase III: these trials are used in groups of several hundred to several thousand people. They are used to monitor any adverse effects of the drug, as well as compare it to other conventional or experimental treatment methods.
- Phase IV: these studies test the drug in the general population to determine any long-term adverse effects, as well as potential usage in treatment of other conditions.
Ask your doctors about the availability of clinical trials, including whether you are suitable, and any benefits, risks and potential complications that may arise.
Palliative care
Palliative care aims to improve the patient’s quality of life and alleviate symptoms, without trying to cure the disease. This option is beneficial for patients with advanced Oesophageal cancer at any stage of treatment, not just towards the end of life. It can also be used in conjunction with other treatment options, such as surgery, radiotherapy and chemotherapy, with the intention of relieving pain, alleviating symptoms and meeting your physical, emotional, cultural and spiritual needs.
Risk factors
The risk factors for Oesophageal cancer will vary depending on the type you have.
Risk factors for Oesophageal Adenocarcinoma include:
- Being overweight or obese.
- Having pre-existing conditions of the gastrointestinal tract (e.g., Barrett’s oesophagus or gastro-oesophageal reflux disease (GORD)).
- Smoking tobacco.
- Being over 60 years of age.
- Inherited medical conditions such as Peutz-Jeghers syndrome (PJS) or Cowden syndrome.
Risk factors for Oesophageal squamous cell carcinoma include:
- Drinking alcohol.
- Smoking tobacco.
- Being over 60 years of age.
- Prior oesophageal damage.
Not everyone with these risk factors will develop the disease, and some people who have the disease may have none of these risk factors. See your general practitioner (GP) if you are concerned.
Early symptoms
Early-stage oesophageal cancer may present with little to no symptoms. As the tumour progresses, some of the following symptoms may appear:
- Difficulty swallowing.
- New heartburn or reflux.
- Worsening indigestion.
- Food or liquids ‘catching’ in the throat or choking episodes when swallowing.
- Pain when swallowing.
- Unexplained weight loss.
- Unexplained loss of appetite.
- Discomfort in abdomen.
- Fatigue.
- Vomit or stool with blood.
Not everyone with the symptoms above will have cancer but see your general practitioner (GP) if you are concerned.
Diagnosis/diagnosing
If your doctor suspects you have oesophageal cancer, they will order a variety of tests to confirm the diagnosis and refer you to a specialist for treatment.
Imaging & blood tests
The doctor will take images of your body using a computed tomography scan (CT scan), x-ray, and/or positron emission tomography (PET scan), depending on where the suspected the cancer is. The doctor may also look at other parts of the body and looks for signs of metastasis. Additionally, a blood test may be taken to assess your overall health and help guide treatment decisions.
Endoscopy & biopsy
An endoscopy is a surgical procedure that involves inserting a long, flexible tube with a light and small camera through your throat, oesophagus and small bowel, in order to examine the lining of the gastrointestinal tract and detect any abnormalities. You will be given a sedative or anaesthetic throughout the procedure. You will be asked to fast for several hours prior to the procedure. An endoscopy is often done as a day surgery. Your doctor will discuss the risks and any possible complications of this procedure prior to the procedure.
Throughout the procedure, your doctor may also perform an endoscopic ultrasound to guide the needle during a biopsy, or to check for signs of cancer metastasis.
If any abnormalities are observed, your doctor will remove a small tissue sample for analysis.
Prognosis (Certain factors affect the prognosis and treatment options)
Unfortunately, the general prognosis for oesophageal cancer remains poor. While it is not possible to predict the exact course of the disease, your doctor may be able to give you a general idea based on stage, rate/depth of tumour growth, susceptibility to treatment, age, overall fitness and medical history. Generally, early-stage oesophageal cancers have a better prognosis. However, if the cancer is advanced and has spread, the prognosis may not be as good and there may be a higher risk of cancer recurrence.
References
Some references are to overseas websites. There may be references to drugs and clinical trials that are not available here in Australia.