Oesophageal cancer

What is oesophageal cancer?

The oesophagus is part of the body's digestive system, the tube which links the stomach to the mouth. Muscles in the oesophagus push food down into the stomach during the swallowing process.

There are two main types of oesophageal cancer, with different implications for treatment and prognosis:

• Squamous cell carcinoma - tends to occur in the upper third and middle of the oesophagus, developing from the flat cells that line the tube (about half of UK cases)
• Adenocarcinoma - develops from mucus-making cells in the lower third of the oesophagus (incidences of this type have risen considerably in recent years, probably related to an increase in acid indigestion and reflux)

Oesophageal cancer risk factors

It's not yet fully understood why oesophageal cancer develops, but risk factors may include:

• Age - like most cancers, it's more common in older people, particularly those aged 50-70
• Gender - men are slightly more at risk than women
• Smoking
• Heavy alcohol consumption
• Damage to the oesophagus by irritant substances
• Being overweight
• Poor diet, lacking in vitamins and particularly heavy in barbecued or roasted meat
• Previous problems with a condition called Barrett's oesophagus, where abnormal cells develop in the lining of the lower part, usually in people with a long history of acid reflux or heartburn. Although not a cancerous condition, the cells can occasionally lead to cancer. Barrett's oesophagus affects one in 10 people in the UK with chronic acid reflux (see below), but only one per cent each year go on to develop cancer
• Reflux, where food and stomach juices pass back up into the oesophagus from the stomach

Oesophageal cancer symptoms

Because of the tumour's location, many symptoms are related to eating food, including:

• Problems with swallowing, including burning sensations
• Sensation that food is getting stuck on the way down, particularly when swallowing larger pieces of food
• Weight loss
• Acid indigestion and reflux, which can cause pain in the back or throat
• Chronic cough or hoarse voice
• Nausea
• Heartburn
• Frequent vomiting or choking
• Coughing or vomiting blood

Of course, all of these symptoms can mean something far less serious is wrong. Many are typical of indigestion, which is very common and not usually serious, people may just keep taking antacids.

Doctors urge patients with persistent symptoms of this kind to arrange an appointment. As well as a general physical examination, the doctor or a hospital specialist uses a variety of tests to try to locate the source of the problem.

Diagnosing oesophageal cancer

The main diagnostic test is an endoscopy, where a long tube with a light and camera on the end is passed down into the oesophagus to look at the tissues and take samples (a biopsy) of any abnormal areas. This procedure is sometimes referred to as an oesophago-gastro-duodenscopy (OGD) when the doctor examines the whole of the upper bowel to check for problems. The patient is generally given a local anaesthetic to the back of the throat before the tube is inserted, to prevent gagging, but heavier sedation or a general anaesthetic can be given if necessary.

Sometimes other tests are done such as a barium x-ray, blood tests to check for chemical markers of cancer or even a CT or MRI scan (which can be used to check other abdominal organs too).

Oesophageal cancer treatments

As with most cancers, if a case of oesophageal cancer is found, the first step is to work out the type of cancer and how far it has spread, called staging, which helps to plan the most appropriate treatment.

Treatments that you may be offered include:

• Surgery - what exactly is done will depend on the stage of the cancer. Often the tumour is removed, along with nearby lymph nodes and other tissues. The tube is then repaired so the patient can swallow food. In other cases, a section of the lower intestine may be used to replace the removed part of the oesophagus or to bypass a whole area if the tumour is too large.
• Chemotherapy - relieves symptoms and may slow cancer growth. It may be used to shrink the tumour before surgery or when surgery is not an option because the tumour has spread.
• Radiotherapy - may be used to shrink a tumour before surgery. It may be given on its own, in combination with chemotherapy or after surgery to try to prevent recurrence.
• Laser treatment - may help to reduce the size of the tumour and relieve symptoms but is not curative. Laser treatment may be combined with the use of a light-sensitive drug (known as photo-dynamic therapy or PDT)
• Insertion of a stent - a rigid tube is placed in the oesophagus to help keep it open and allow food to pass through to the stomach. It can help deal with symptoms but does not treat the cancer itself.
• Biological therapies - made from chemicals that occur naturally in the body such as antibodies, or substances that counteract the effect of the protein signalling molecules which naturally stimulate growth of the cells (known as growth factor blockers). Another type of biological therapy is a vaccine, which can stimulate the immune system to identify cancerous cells and destroy them.

Patients with oesophageal cancer are often encouraged to eat little and often, as large meals can be difficult to swallow. Weight loss is a frequent result of problems eating caused by the cancer, and dietary supplements are sometimes given.

Unfortunately, early detection of oesophageal cancer is unlikely because smaller tumours produce fewer symptoms. The cancer has often reached an advanced stage by the time it's diagnosed and it doesn’t usually respond very well to treatment. In later cases, many of the treatments offered aim to extend life and relieve symptoms.

Some of these treatments aren’t yet proven and may be available only as part of clinical research trials, to see if a more effective combination of therapies can be found.