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Esophageal Cancer

Anatomical facts:

The esophagus is a hollow muscular tube that carries food and liquids from the mouth to the stomach. The esophagus is about 10-13 inches long, and in its smallest point it is a little less than 1 inch wide. The esophagus connects to the mouth at the top, and to the stomach at the bottom, through special round-shaped muscles calls sphincters. The sphincters have the ability to open and close in order to enable food to go in and out while preventing stomach acids from entering the esophagus.

The American Cancer Society estimates that every year, about 15,000 new cases of this cancer are diagnosed in the United States. This disease affects three-to-four times more men than women and is about 50% more common in African Americans than in white Americans. Even though survival rates are still poor, they have been improving steadily since the 1960’s.

Esophageal cancer diagnosis

Esophageal cancer is associated with gastroesophageal reflux disease (GERD) and especially with Barrett’s esophagus. This condition develops if GERD has caused a change in the cells of the esophagus. The abnormal cells are still not cancer, but they may become malignant over time. It is estimated that people with Barrett’s esophagus are about 50 times more likely to develop esophageal cancer than the general population. Alcohol and tobacco are major risks for esophageal cancer, and the combination of smoking and drinking alcohol raises a person’s risk much more than using either alone.

Types:

There are two main types of cancer of the esophagus. Squamous cell carcinoma may occur along the length of the esophagus and accounts for slightly less than half of esophageal cancers. The majority of esophageal cancers are adenocarcinomas that grow near the intersection of the esophagus and the stomach. Adenocarcinomas develop in cells that were damaged as a result of GERD.

Esophageal Cancer Treatment

The choice of treatment for esophageal cancer depends on various factors – such as stage and type of cancer, health of the patient and personal preferences of the patient.

Surgery

Surgery is the most recommended treatment for esophageal cancer. However, at present surgery alone is used only for early stage esophageal cancer. Surgery can be performed by making a large incision in the abdomen (open surgery) or by using an instrument called laparoscope (laparoscopy).

The types of surgical procedures used are the following:

Surgical excision of small tumors: It involves removal of small tumors in the esophagus with the help of surgery. An endoscope can be used to make the surgery less invasive.

Esophagectomy: This refers to the surgical removal of the cancerous part of the esophagus. The stomach is then joined to the end of the esophagus. A part of the colon or a plastic tube may be used to connect the esophagus to the stomach. Lymph nodes near the esophagus, where cancer may spread, are removed.  They are examined by a pathologist to find the extent to which cancer has spread.

Esophageal stent placement: A large tumor may obstruct the movement of food in the esophagus. In such situations, a stent is used to force the esophagus to remain open so that food can pass down to the stomach.

Esophagogastrectomy: It involves the removal of the lower esophagus and a portion of the upper stomach. The rest of the esophagus is then joined to the stomach.

Radiation therapy

Radiation therapy refers to the use of high energy radiation to treat cancer. Radiation can be given in the following ways:

External radiation therapy: A beam of radiation from a machine outside the body is aimed at the affected site of the patient’s body.

Internal radiation therapy or brachytherapy: Radioactive substance sealed in small pellets is placed near the affected region. Cancer cells are killed by the radiations emitted from the radioactive substances.

A plastic tube is used to keep the esophagus open when radiation is given.

Radiation therapy can be given before or after surgery for stages II and III of esophageal cancer. For advanced stages (Stage IV) it is mostly used to relieve symptoms.

Chemotherapy

Chemotherapy is the use of drugs for the treatment of cancer. It can be used alone or in combination with radiation therapy. When drugs are administered through a vein or by mouth, then this kind of chemotherapy is called systemic chemotherapy. Direct administration of drugs to the affected region is called regional chemotherapy.

Chemotherapy can be given before surgery to shrink the tumor in the esophagus. It can also be used at an advanced stage to relieve symptoms, inhibit the progression of cancer and reduce the chances of recurrence of cancer.

Laser therapy

Laser therapy refers to the use of a laser beam for the treatment of esophageal cancer. The beam can precisely cut off the tumor.

Electrocoagulation

Electrocoagulation refers to the use of electric current to kill cancer cells. In this procedure, the surgeon inserts a probe in the tumor through which electric current is transmitted. The cancer cells are killed by the heating caused by the flow of electric current.

Photodynamic therapy

Photodynamic therapy (PDT) is a new form of cancer treatment that uses a light sensitive drug and a certain type of laser light to kill cancer cells. The drug after administration accumulates more in the tumor cells than normal cells. It is then activated by a special type of laser light which is focused on the affected region. The active drug then kills the cancer cells. This treatment has minimum side effects. PDT does not cure esophageal cancer. It is mainly used as a palliative treatment. It may be used to relieve pain while swallowing food.

Targeted therapy

Targeted therapy helps in preventing the growth of tumor cells by blocking some of the enzymes required for cell growth. Many targeted therapies are in clinical trials. Some of them which can be used are the monoclonal antibodies and signal transduction/tyrosine kinase inhibitors for EGFR, monoclonal antibodies to the HER2/neu receptor and VEGF ligand, oral COX-2 inhibitors, and other novel drugs.

Bevacizumab, which targets VEGF and act as an angiogenesis (blood vessel formation) inhibitor is in clinical trials for treatment against locally invasive and metastatic esophageal cancer.

Prognosis:

Unfortunately, many esophageal cancer cases are not discovered until they reach the advanced stage, when cure is not possible. In these cases, the goal of surgery is to improve swallowing and nutritional status. Photodynamic therapy and mechanical stems also may relieve this problem. Patients with advanced esophageal cancer may also benefit from radiation therapy and chemotherapy, which may help reduce the severity of symptoms and improve the quality of life.

Esophageal cancer survivors may suffer from swallowing problems that cause severe weight loss. A soft diet of calorie-rich food may be helpful, but sometimes patients need additional nutritional support through artificial feeding. Food in liquid form is delivered directly to the stomach through a tube inserted into the stomach through an opening in the skin of the abdomen. Pain control is another concern and can be managed effectively by the patient’s medical team.

Clinical trials

Clinical trials refer to those kinds of treatment which are not yet standardized. It is a part of research that aims to develop better strategies for the treatment of cancer. The patients may willingly participate in clinical trials.

References

Tougeron D, Richer JP, Silvain C. Management of esophageal adenocarcinoma. J Visc Surg. 2011 Jun; 148(3):e161-70.

Campbell NP, Villaflor VM. Neoadjuvant treatment of esophageal cancer. World J Gastroenterol. 2010 Aug 14; 16(30):3793-803. Review.

Krasna MJ. Multimodality therapy for esophageal cancer. Oncology (Williston Park). 2010 Nov 15; 24(12):1134-8.

Additional resources:

American Cancer Society. Learn about Esophagus Cancer. Access at:  www.cancer.org and select from the menu under “Choose a Cancer Topic.”

Ginex, Pamela, Jacqueline Hanson, and Bart L. Frazzitta. 2005. /100 Questions and Answers about Esophageal Cancer. Sudbury, MA: Jones and Bartlett. Detailed information about esophageal cancer is presented in an easy-to- read question-and-answer format. This book was co-authored by a lymphoma specialist, an oncology nurse, and a lymphoma survivor.

National Cancer Institute. Esophgeal Cancer. Access at: www.cancer.gov and click on “Types of cancer.” The top page of the section links to patient versions of PDQ@ statements, clinical trial information, and other NCI publications on this topic.

People Living with Cancer. Esophageal Cancer. Access at: www.plwc.org and click on “Cancer Type.” The PLWC oncologist-approved esophageal cancer guide can be printed in its entirety or by subtopic.

This article was originally published on 7/12/2014 and last revision and update of it was 9/14/2015.