Cancer, oesophageal

Page last reviewed: 13/07/2011

Cancer of the oesophagus, also known as oesophageal cancer, is an uncommon but serious type of cancer that affects the oesophagus (gullet). Presenting symptoms or signs of oesophageal cancer include:

  • difficulties swallowing (dysphagia) is by far the commonest presentation
  • anaemia
  • hiccups
  • weight loss
  • persistent severe reflux
  • throat pain
  • persistent cough

The oesophagus

The oesophagus is the medical name for the gullet, which is part of the digestive system. The oesophagus is a long tube that carries food from the throat to the stomach. The top part of the oesophagus lies behind the windpipe (trachea). Ir runs down the chest between the spine and the heart adn joins the stomach in teh abdomen, usually an inch or two below the lower part of the sternum (breast bone).

Types of oesophageal cancer

There are two main types of oesophageal cancer:

  • Squamous cell carcinoma forms in the upper part of the oesophagus. It occurs when cells on the inside lining of the oesophagus multiply abnormally. This cancer is directly related to tobacco use.
  • Adenocarcinoma of the oesophagus forms in the lower part of the oesophagus. It occurs when cells inside the mucus glands that line the oesophagus multiply abnormally. The mucus glands produce a slimy substance to help food slide down the oesophagus more easily.

How common is oesophageal cancer?

Oesophageal cancer is uncommon, but it is not rare. There are about 390 new cases diagnosed each year.

Oesophageal cancer mainly affects people who are over 55 years of age, with the average age at diagnosis being 72. The condition is more common in men than in women.

Smoking and drinking alcohol are two of the biggest risk factors for oesophageal cancer, (squamous type) particularly if both activities are combined. People who drink heavily but do not smoke are four times more likely to develop oesophageal cancer than non-drinkers, and people who smoke and do not drink alcohol are twice as likely to develop oesophageal cancer.

However, people who smoke and drink heavily (more than 30 units a week) are eight times more likely to develop oesophageal cancer than those who do not smoke or drink.

Adenocarcinoma of the oesophagus is now the commonest type of oesophageal cancer in Ireland. This cancer arises usually in the context of chronic or severe reflux disease. Obesity is also a significant risk factor.

Outlook

Oesophageal cancer does not usually cause any noticeable symptoms until the cancer has spread beyond the oesophagus and into nearby tissue. Therefore, the outlook for oesophageal cancer is relatively poor compared with other types of cancer.

An advanced stage at presentation, as well as often old age or frailty of the patient means that many cannot be treated for cure, and overall only 30% of patients will live for one year after the diagnosis, and approximately 10% for 5 years.The outlook improves in cases where the cancer is diagnosed at an early stage (Stage 1 to 3), and where a cure is possible. In such cases it is estimated that 34-42% of people will live for five years after the diagnosis and most of these will be cured. 

Curative approached for oesophageal cancer usually involves surgical resection, increasing chemotherapy +radiotherapy is administered prior to surgery. In some scenarios surgery is avoided and high-dose radiation therapy with chemotherapy is the preferred treatment..

On average, 30% of people with oesophageal cancer will live for one year after the diagnosis, and 8% will live for five years after the diagnosis.

The outlook improves in cases where the cancer is diagnosed at an early stage, and where a cure is possible. In such cases it is estimated that 34-42% of people will live for two years after the diagnosis, and that some people may live much longer.

Attempting to cure oesophageal cancer involves having a course of chemotherapy (and radiotherapy as well in some cases) followed by surgery to remove the cancerous section of the oesophagus.

If a cure is not achievable, it is usually still possible to relieve symptoms and slow the spread of the cancer using a combination of radiotherapy, chemotherapy and surgery.  

Page last reviewed: 13/07/2011

When cancer of the oesophagus first develops, it rarely causes any symptoms. This is due to the fact that, initially, the tumour is very small. It is only when the cancer starts to become larger and more advanced that the symptoms will start to develop.

Difficulty swallowing

Difficulty swallowing (dysphagia) is the most common symptom of oesophageal cancer. However, you will not usually experience any difficulty swallowing until the tumour has grown large enough to narrow your oesophagus to about half its normal width.

As the tumour narrows your oesophagus it becomes more difficult for food to pass down. When you swallow it can feel as if food is stuck in your gullet, as the muscles of the oesophagus try to push it past the tumour.

You may find that you have to chew your food more thoroughly, or that you can only eat soft foods. If the tumour continues to grow, even liquids can be difficult for you to swallow.

Other symptoms

Other symptoms of oesophageal cancer include:

  • unexplained weight loss (caused by a combination of having difficulties swallowing and the cancer's harmful effects on your body)
  • throat pain and discomfort
  • indigestion
  • hoarseness
  • persistent cough
  • vomiting
  • coughing blood

When to seek medical advice

You should contact your GP if you experience difficulties swallowing that last for more than a week.

You should also contact your GP is you have severe unexplained reflux disease.

Dysphagia can have a wide range of causes, which means that your symptoms are unlikely to be related to oesophageal cancer. However, a formal diagnosis of your symptoms is recommended.

 

Page last reviewed: 13/07/2011

Cancer

Cancer begins with an alteration to the structure of the deoxyribonucleic acid (DNA) that is found in all human cells. This is known as a genetic mutation. The DNA provides the cells with a basic set of instructions, such as when to grow and reproduce.

The mutation in the DNA changes these instructions so that the cells carry on growing. This causes the cells to reproduce in an uncontrollable manner, producing a lump of tissue that is known as a tumour.

How cancer spreads

Most cancers grow and spread to other parts of the body via the lymphatic system. The lymphatic system is a series of glands (or nodes) that are located throughout your body in a similar way to your blood circulation system. The lymph glands produce many of the specialised cells that are needed by your immune system (the body's natural defence against disease and infection).

Left untreated, oesophageal cancer spreads through the outer lining of the oesophagus and into nearby organs, such as the liver, lungs or stomach.

Risk factors

Exactly what causes oesophageal cancer to develop is uncertain. However, it appears that repeated and prolonged exposure of the lining of the oesophagus to toxic substances is a significant risk factor.

Known risk factors for oesophageal cancer are explained below.

Alcohol

Drinking too much alcohol increases your risk of developing a number of illnesses and conditions, including cancer of the oesophagus. Long-term heavy drinking causes irritation and inflammation in the lining of the oesophagus. If the cells in the lining of your gullet become inflamed, they are more likely to become malignant (cancerous).

Smoking

Using any form of tobacco (including cigarettes, cigars, pipes and chewing tobacco) will increase your risk of developing cancer of the oesophagus.

When you smoke tobacco you always swallow some of the smoke, which contains many harmful toxins and chemicals. These substances irritate the cells that make up the lining of the oesophagus, which increases the likelihood that they will become malignant.

The longer you smoke, the greater your risk of developing oesophageal cancer.

Gastro-oesophageal reflux disease (GORD)

A valve, known as a cardiac sphincter, is located between your stomach and oesophagus. The valve usually only opens when food is ready to pass from your oesophagus into your stomach. 

Sometimes, the valve becomes weakened or it relaxes at the wrong time. This condition is known as gastro-oesophageal reflux disease (GORD).

If you have GORD, stomach acid is able to travel up into your oesophagus. When this happens, it causes heartburn, which is a form of indigestion that causes pain in the front of your chest.

However, it should be stressed that the risk of developing oesophageal cancer from GORD is very small, and most people with GORD will not go on to develop cancer. 

Barrett's oesophagus

If you have chronic acid reflux, it can sometimes lead to you developing another condition called Barrett's oesophagus. Barrett's oesophagus causes new cells to develop in the lower oesophagus, which are very similar to stomach cells. These abnormal cells are resistant to stomach acid, but they are more likely to become malignant in the future.

Approximately one person out of 10 who have chronic acid reflux goes on to develop Barrett's oesophagus. You are more at risk if you have had chronic acid reflux for a prolonged period of time. About one person in 100 with Barrett's oesophagus develops cancer of the oesophagus.

Obesity

If you are severely overweight, your risk of developing cancer of the oesophagus is approximately double, compared with if you were a healthy weight for your height. This may be because obese people are more at risk of developing Barrett's oesophagus (see above).

Diet

A diet that is low in fruit and vegetables, or lacks vitamins A, C, B1 or zinc has been shown to increase the risk of cancer of the oesophagus. If you eat a healthy, balanced diet, you will usually get enough vitamins and zinc in your diet naturally.

Cancer of the oesophagus is much more common in the Far East and Central Asia. It is thought that this may be due in part to the type of diet that is consumed in these countries, which includes far fewer uncooked vegetables than the western diet. It may also be due to environmental factors. 

Ageing

It is very rare for anyone who is under 45 years of age to develop cancer of the oesophagus. Most people who develop the condition are between 55 and 70 years of age. Cancer of the oesophagus is nearly twice as common in men than it is in women.

Chemicals and pollutants 

Long-term exposure to certain chemicals and pollutants may irritate your oesophagus, particularly if you inhale these substances. Chemicals and pollutants that are known to increase the risk of oesophageal cancer include:

  • soot
  • metal dust
  • vehicle exhaust fumes
  • lye (a chemical that is found in strong industrial and household cleaners)
  • silica dust (which comes from materials such as sandstone, granite and slate)

If you have to work with these substances as part of your job, make sure you take all the necessary health and safety precautions. This should help to minimise your exposure to these potentially harmful substances.

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Page last reviewed: 13/07/2011

If your GP suspects you may have cancer of the oesophagus, they will first take a detailed look at your medical history, before carrying out a physical examination. During this examination your GP will look for any signs of abnormalities, such as a lump in your abdomen, which may indicate a tumour.

If your GP still suspects oesophageal cancer, you will be referred for further tests at a hospital. Some of the tests you may receive are outlined below.  

Endoscopy  

This is one of the first tests you will have to help confirm a diagnosis of cancer of the oesophagus.

Endoscopy is a medical procedure that allows doctors to see inside the body. During this procedure, a thin flexible telescope, called an endoscope, is passed through your mouth and down towards your stomach.

The endoscope has a light attached to the end, and feeds back the images of your oesophagus to a monitor. This will allow your doctor to look for any signs of abnormal cells or tumours.

Before having an endoscopy, you should avoid eating for several hours, as food can obstruct the view of the endoscope.

An endoscopy should not cause you any pain, although it may feel uncomfortable. Before the endoscopy takes place, you will normally be given a local anaesthetic or sedative, to help you relax, and to help make the procedure less uncomfortable. The endoscopy itself will usually take about 15 minutes, although you should allow approximately two hours for your visit.

You may notice that you have a sore throat following an endoscopy, which will usually last for a few days. If your symptoms persist, see your GP.  

Biopsy 

If the specialist carrying out your endoscopy finds any indication of an abnormality, then a sample of cells can be taken (biopsy). This is done by using a special extracting instrument that is connected to the endoscope.

This biopsy will then be examined underneath a microscope in a laboratory. The results of the biopsy will show whether the cells are malignant (cancerous) or benign (non-cancerous). The results will normally take seven to ten days to come back.  

Barium swallow  

A barium swallow is a test that involves you drinking thick, white-coloured liquid called barium. Once you have swallowed the barium, you will undergo a series of X-rays.

The barium coats the lining of your oesophagus, so that it shows up on the X-ray. These X-rays are able to show your doctor whether there is any obstruction in your oesophagus, which may be an indication of a tumour.

You may have to undergo this test if your cancer has already been diagnosed, as it will help your doctor to assess the size of your tumour.

A barium swallow usually takes about 15 minutes to perform. After the procedure, you will be able to eat and drink as normal, although you may need to drink more water, to help flush the barium out of your system.  

Endoscopic ultrasound  

Once cancer of the oesophagus has been diagnosed, your doctor will need to assess how far the cancer has spread, (i.e. stage the cancer),and how large the tumour has grown.

An endoscopic ultrasound will help your doctors to assess how far your oesophageal cancer has progressed. It involves having a very small ultrasound probe passed into your oesophagus using an endoscope. This test produces sound waves, which can penetrate the surrounding tissues.

These waves are then used to produce an image of your oesophagus, so your doctor can see if the cancer has spread to the surrounding tissue.  

Computerised tomography (CT) scan  

CT scan takes a series of X-ray images of your body and uses a computer to put them together. This then creates a very detailed picture of the inside of your body. A CT scan is often nowadays combined with a PET scan (CT-PET) for full comprehensive staging.

A CT scan will help your doctor assess how advanced your cancer is. It allows them to see whether the cancerous cells have formed tumours in any other places within the body. A CT scan will allow your doctors to work out which type of treatment will be most effective and appropriate for you.  

Staging

The above tests will usually determine what stage your cancer is at, what you need in terms of your treatment and the possibility of achieving a complete cure.

The stages of oesophageal cancer are described below.

  • Stage 1: the cancer is limited to the top layers of the lining of the oesophagus, or is only in a small part of the oesophagus. It has not spread to nearby tissue or lymph nodes.
  • Stage 2A: the cancer has spread into the layer of muscle in the wall of the oesophagus, but has not spread to nearby lymph nodes.
  • Stage 2B: the cancer has spread to both the muscle layer and into nearby lymph nodes.
  • Stage 3: the cancer has spread through the wall of the oesophagus and into nearby lymph nodes and the surrounding tissue. However, it has not spread into other parts of the body.
  • Stage 4: the cancer has spread into other parts of the body, such as your liver, lungs or stomach.

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Page last reviewed: 13/07/2011

Cancer treatment team

Many hospitals have multidisciplinary teams that treat oesophageal cancer

If you have oesophageal cancer, you may see several or all of the healthcare professionals listed here as part of your treatment.

Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will be yours.

Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist. For example, you may want to find out what the advantages and disadvantages of particular treatments are.

Your treatment plan

Your recommended treatment plan will depend on what stage your cancer is at.

Stage 1 and 2 oesophageal cancer is usually treated by surgically removing the cancerous section of the oesophagus and, if necessary, the nearby lymph nodes. This type of surgery is known as an oesophagectomy. Chemotherapy is usually given before surgery to reduce the risk of the cancer returning.

For Stage 2 cancer chemotherapy alone or combined with radiation therapy prior to surgery may be considered. In a small subset of patients where the tumour is in its earliest stage (confined to inner lining) surgery down the endoscope, known as endoscopic mucosal resection (EMR), can be considered.

Stage 3 oesophageal cancer is usually treated by surgically removing the cancerous section of the oesophagus, nearby lymph nodes and the upper section of your stomach. This type of surgery is known as an oesophagogastrectomy. As with an oesophagectomy, before surgery it is likely that you will be given chemotherapy and possibly radiotherapy.

In cases of stage 4 oesophageal cancer, the cancer has usually spread too far for a cure to be possible. Radiotherapy and chemotherapy can be used to slow down the spread of the cancer and to relieve symptoms. Surgery may also be used to help relieve the symptoms of dysphagia (difficulty swallowing).

Surgery

Oesophagectomy

During an oesophagectomy, your surgeon will remove the section of your oesophagus that contains the tumour. The remaining section of your oesophagus will then be reconnected to your stomach. If your stomach cannot be pulled up to meet your oesophagus, a small section of your large intestine may be used to make the connection.

Oesophagogastrectomy

During an oesophagogastrectomy, the cancerous section of your oesophagus will be removed, as well as the upper part of your stomach and surrounding lymph nodes. The remaining section of your oesophagus and your stomach may be reconnected using part of your large intestine.

To access your oesophagus, your surgeon will either need to make an incision (cut) in your abdomen and chest, or in your abdomen and neck.

Self-expanding stents

Self-expanding stents are another method of relieving the symptoms of dysphagia. The treatment involves placing a small metal tube into your oesophagus. The stent expands to hold open your oesophagus, which helps to make swallowing easier.

Chemotherapy

Chemotherapy is a type of cancer treatment that uses anti-cancer medicines either to kill the malignant (cancerous) cells in your body or to stop them multiplying. Chemotherapy medicines can either be injected or given to you orally (by mouth).

As well as attacking cancerous cells, chemotherapy can also attack the normal, healthy cells in your body, which is why this form of treatment has many potential side effects.

The most common side effects of chemotherapy include:

  • vomiting
  • hair loss
  • nausea
  • mouth sores
  • fatigue

These side effects are usually only temporary, and you should find that they improve once you have completed your treatment. 

Chemotherapy treatment is often used alongside surgery and radiotherapy (see below) to help ensure that as much of the cancer as possible is treated.

Radiotherapy

Radiotherapy is a form of cancer therapy that uses high energy beams of radiation to help shrink your tumour and relieve pain.

Radiotherapy for oesophageal cancer should make it easier for you to swallow because the radiation decreases the size of the tumour and makes it less obstructive.

The side effects of radiotherapy include:

  • fatigue
  • skin rashes
  • loss of appetite
  • sores in your oesophagus

These side effects are usually temporary, and you should find that they improve once you have completed your treatment. 

As with chemotherapy, radiotherapy is often used alongside surgery to help make the tumour easier to remove.

Nutritional support

If your dysphagia symptoms are severe, you may find it very difficult to eat and drink in the normal way, which could place you at risk of malnutrition and dehydration.

Another problem that can occur is known as tracheoesophageal fistula. This is when the cancer creates a hole between your oesophagus and your windpipe (trachea). This may cause you to cough and gag, particularly when you try to swallow.

While surgery can be used to treat tracheoesophageal fistula, and relieve the symptoms of dysphagia, you may need to use an alternative method of receiving the nutrients your body requires while waiting for surgery.

A percutaneous endoscopic gastrostomy (PEG) tube is often used to provide your body with the nutrients that it needs. A PEG is a tube that is surgically implanted directly into your stomach. It passes through a small incision (cut) on the surface of your abdomen (stomach).

See the Health A-Z topic about Dysphagia - treatment for more information about PEG tubes.

Treatment teams

An MDT is made up of a number of different specialists including:

  • surgical oncologist (a specialist in the surgical treatment of cancer)
  • radiation oncologist (a specialist in radiation therapy)
  • medical oncologist (specialist in drug treatment)
  • pathologist (a specialist in diseased tissue)
  • radiologist (a specialist in imaging e.g. CT scans)
  • social worker
  • specialist cancer nurse, who will usually be your first point of contact

Targeted therapy

Research is continuing into new ways of treating oesophageal cancer. Most of the research has focused on a type of treatment known as targeted therapy. Targeted therapy involves using medication that specifically targets the biological functions that cancer needs to grow and spread.

For example, there is a type of medication called growth factor blockers. These block the effects of proteins that help stimulate the growth of new cancer cells.

Initial research has been encouraging, and further research is required to see how effective and safe these types of new medication are.

Page last reviewed: 13/07/2011

Give up smoking

As well as being a significant risk factor for oesophageal cancer, smoking is also a major contributor to many serious diseases, such as heart disease and lung cancer, and it is the biggest cause of death and illness in Ireland.

If you decide to stop smoking, your GP will be able to refer you to your local smoking cessation service, which will provide you with dedicated help and advice about the best ways to give up smoking.

You can also call the National Smokers Quitline at 1850 201 203, or log on to www.quit.ie, or the HSE facebook page at www.facebook.com/hsequit.

If you are committed to giving up smoking but do not want to be referred to a stop smoking service, your GP should be able to prescribe medical treatment to help with any withdrawal symptoms that you may experience after quitting.

Alcohol

Alcohol is another significant risk factor for oesophageal cancer, as well as for other serious conditions, such as heart attack, stroke and liver disease.

The recommended weekly limits of alcohol consumption are:

  • 17 standard drinks of alcohol for men
  • 11 standard drinks of alcohol for women

A standard drink of alcohol is equal to about half a pint of normal strength beer, a small glass of wine or a pub measure of spirits.

Lose weight

If you need to lose excess weight, exercising regularly and eating a healthy, balanced diet can help. If you are very overweight, or obese, losing weight will help to reduce your risk of developing cancer of the oesophagus.

The most successful weight loss programmes include at least at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity (i.e. cycling or fast walking) every week, eating smaller portions and only having healthy snacks between meals. A gradual weight loss of around 0.5kg (1.1lb) a week is usually recommended.

A low fat, high fibre diet that includes whole grains and plenty of fresh fruit and vegetables (at least five portions a day) is recommended.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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