Esophageal Cancer

What is the Esophagus?

The esophagus is a muscular tube connecting the oral cavity to the stomach. It is made up of muscle tissue of various types, and actively propels food to the stomach when functioning properly. It is about 10 inches (25cm) in length and lies in the chest cavity between the trachea (windpipe) and spinal column. The muscular layers of the esophagus are covered by specialized protective cells known as epithelial cells that are replenished, when necessary, to keep the body and digestive tract healthy.

What is cancer?

Although there are many types of cancer, they all share common characteristics that allow doctors to group them together when discussing general characteristics. Generally, normal cells become abnormal, dividing too often and are unable to regulate their growth the way normal cells can. As these abnormal cells build up, they begin to form a mass known as a tumor. Tumors can be classified as benign or malignant based on their ability to spread and their potential to be life threatening.

What are the causes of esophageal cancer, and can I do anything to prevent it?

Specifically, esophageal cancer, while much more common in some parts of the world, accounts for only about one percent of all cancers in the United States. This particular type of cancer tends to be found in patients over 55 years of age and is twice as likely to be diagnosed in a man than in a woman. In addition, it is more common in African-Americans than in white people. While the exact cause of cancer of the esophagus is not yet known, doctors and researchers have identified several risk factors which can significantly increase the risk of developing esophageal cancer. In the United States, smoking tobacco and excessive use of alcohol can put one at increased risk for developing esophageal cancer. Heavy smokers who drink alcohol excessively are much more likely than the general population to be diagnosed with esophageal cancer. Reduction or cessation of these harmful activities reduces the risk of getting esophageal cancer and can also decrease your chance of developing other cancers and problems of the respiratory and digestive systems.
Chronic irritation of the lower esophagus is also a risk factor for the development of cancer of the esophagus. When the lower esophagus is repeatedly exposed to the harmful acidic contents of the stomach (gastroesophageal reflux), the cells are transformed to better withstand these harsh conditions. A change in the esophageal lining known as Barrett's esophagus puts a person at risk for developing a cancer in this area. Diagnosis and control of reflux, medically and surgically, can reduce the chances that Barrett's esophagus will eventually lead to cancer in this area. Also, irritation from the ingestion of caustic substances can place patients at increased risk of developing esophageal cancer for several years after the time of injury.

Many times, esophageal cancer develops in patients with no clear cut risk factors. When this happens, it is likely a combination of known and unknown factors which contributes to the formation of a malignancy. Avoiding known risk factors, and the maintenance of a well balanced diet and exercise program is the best means of prevention currently available. Patients who consider themselves at risk for the development of cancer of the esophagus should visit their physician for recommendations regarding evaluation and/or therapy.

What are the symptoms of esophageal cancer?

Many symptoms of esophageal cancer may be caused by less serious health problems and only a physician, after appropriate evaluation, can tell for sure. Early esophageal tumors which are small in size are not usually symptomatic. However, as the tumor increases in size, patients begin to experience difficulty swallowing.
Difficulty swallowing, the most common symptom, worsens as the tumor enlarges and begins to obstruct the normal flow of swallowed food. At first, one notices difficulties with meats, breads and fresh vegetables but as the cancer progresses, even liquids can become difficult to handle.

Other problems associated with esophageal cancer are pain behind the breastbone and frequent, painful bouts of coughing or hiccups. In addition, weight loss and breath odor can be signs of an advancing esophageal malignancy.
It should be noted that quite often, people are able to compensate for early symptoms of esophageal cancer.

For example, avoiding foods that tend to stick may give patients a way to deal with some of the early problems associated with a tumor in the esophagus. In addition, chewing food more completely or drinking more liquids with meals may be ways of compensating for early symptoms ofesophageal cancer. Although symptoms may come and go at first, a patient with recurrent symptoms such as those described above should consult with a physician who can suggest appropriate evaluation if warranted.

How is the cancer diagnosed?

To help make a diagnosis when symptoms are present, regardless of the disease, the doctor will take a detailed history and perform a complete physical exam. In addition to the basic history and physical examination, the physician will most likely order a battery of blood tests and radiologic studies, i.e. x-rays. The tests that are most useful to doctors are a barium swallow (esophagram) and esophagoscopy. To perform a barium swallow, patients must drink a liquid that shows up well on x-ray examinations. By looking at these films, doctors can determine if the shape of the esophagus is suspicious for a mass of some kind. Esophagoscopy is a procedure performed with the patient under intravenous sedation. A long thin camera is used to view the lining of the esophagus and take samples (biopsies) of anything abnormal or suspicious. These biopsies are then studied carefully by a pathologist who specializes in determining whether small samples of tissue are normal or abnormal.
Once a diagnosis of cancer is made, the extent of the disease will help to determine appropriate therapy. This is known as "stage".
Staging the cancer is an attempt to find out if any other parts of the body are involved with the cancer and help guide treatment and also play a role in predicting prognosis. Often, a CT (CAT) scan is performed to help identify the extent of the cancer and is very helpful in determining stage. Occasionally, biopsies of nearby lymph nodes that look suspicious on x-ray are taken to help stage disease and allows doctors to administer the most appropriate therapies.

How is esophageal cancer treated?

Esophageal cancer is difficult to cure unless it is discovered in the earlier stages, before it has begun to spread. Unfortunately, early esophageal cancers are seldom symptomatic and the disease is usually advanced at the time of diagnosis. Esophageal cancer is treated with surgery, radiation therapy or chemotherapy. Doctors may choose different combinations of these treatments based on the specifics of each case.
Most of the time, surgical treatment involves removal of the tumor with a portion of the esophagus. There are several types of incisions that may be used and, usually, the stomach is used to reconnect the upper esophagus to the rest of the gastrointestinal tract. Surgeons choose the type of incision and reconstruction based on what will offer the patient the best chance for cure. Often, patients with esophageal cancer have a poor nutritional status and other medical problems that may limit the procedure that they will be able to tolerate. All of these factors are taken into consideration when decisions about surgical procedures are made by doctors and their patients.

What can I expect during my recovery?

Recovery varies with the overall fitness of the patient and is difficult to predict precisely. However, a minimum of 10-14 days in the hospital should be expected. Patients typically have tubes placed into their small intestine with which tube feedings can be given postoperatively before oral intake is resumed. The anastomosis (hook-up) at the site of tumor resection is protected by inserting a tube that travels through the nose and into the stomach for at least the first week after surgery. In addition, nothing will be permitted by mouth until after an x-ray study is performed to be certain that the anastomosis is intact and water tight. A substantial amount of pain is present in the immediate postoperative period and is controlled with narcotic analgesics in most cases. Early mobilization is critical to an optimal recovery and patients are pushed to ambulate and sit upright as much as possible starting 24-48 hours after surgery. Discharge is anticipated after patients tolerate a soft diet and have demonstrated the strength necessary to function well enough at home. Specific discharge instructions are provided by the department of cardiothoracic surgery.

What is my prognosis?

The prognosis is related to how advanced the cancer is at the time of the diagnosis. Early detection is critical, and may improve a patient's chances of a favorable outcome. Do not ignore swallowing difficulties and have any and all swallowing related problems evaluated by a doctor promptly.

On-Going Research

ESOPHAGEAL MYOTOMY FOR ACHALASIA
Compares thoracoscopic and laparoscopic myotomy for achalasia.

PHOTODYNAMIC THERAPY FOR ESOPHAGEAL CANCER
Studies a minimally invasive method of shrinking obstructing cancers of the esophagus.