Esophageal cancer (patient information)

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Editor-in-Chief: C. Michael Gibson, M.S.,M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Associate Editor-In-Chief: Jinhui Wu, M.D.

Overview
Esophageal cancer is not very common in the United States. The esophagus is a hollow muscular tube, starting in the throat and ending at the stomach, and is used to carry the food you swallow to your stomach to be digested. It is hard to detect esophageal cancer in its early stages. Even if you get symptoms, they may not cause you to be alarmed and seek help from your doctor. However, as the cancer grows, symptoms may include dysphagia, chest pain, weight loss and coughing up blood. Treatments include surgery, radiation, chemotherapy and laser therapy. Esophageal cancer patients also need nutritional support.

What are the symptoms of Esophageal cancer?
Early stages of esophageal cancer do not display any recognizable symptoms. As the malignant tumors grows larger, people may notice one or more of the following symptoms:


 * Dysphagia: This is the most common symptom of esophageal cancer. It causes problems swallowing, with the feeling like the food is stuck in the throat or chest. At first it is often mild, and then gets worse over time. At last, patients can no longer eat and can only consume water.


 * Chest pain or chest burning sensation: Chest pain with swallowing may occur if the tumor is large enough to block the esophagus. Some patients describe a feeling of pressure or burning in the chest.


 * Hiccups: This happens because of digestive dysfunction of the esophagus.


 * Vomiting blood: When a tumor invades a blood vessel, vomiting blood occur. This may be the first symptom in some patients.


 * Weight loss: This occurs because swallowing problems prevent patients from eating enough to maintain their weight. Other factors include loss of appetite and increase in metabolism from the cancer.

Infections or other health problems may also cause these symptoms. Only a doctor can tell for sure. A person with any of these symptoms should tell the doctor so that problems can be diagnosed and treated as early as possible.

What causes Esophageal cancer?
Esophageal cancer is not very common in the United States. It occurs most often in men over 50 years old.

Two main types of esophageal cancer exist: squamous cell carcinoma and adenocarcinoma. These two types look different from each other under the microscope.

Squamous cell esophageal cancer is linked to smoking and alcohol consumption.

Barrett's esophagus, a complication of gastroesophageal reflux disease (GERD), increases the risk for adenocarcinoma of the esophagus. This is the more common type of esophageal cancer. Other risk factors for adenocarcinoma of the esophagus include:


 * Male gender
 * Obesity
 * Smoking

Who is at highest risk?
Studies have found a number of factors that may affect the risk of esophageal cancer. These risk factors are outlined below:


 * Gastroesophageal reflux disease (GERD): In some people, acid can reflex from the stomach into the esophagus. This disease is called Gastroesophageal reflux disease (GERD). Clinical data show that people with GERD have a 2~16 times higher risk of getting adenocarcinoma of the esophagus than those without GERD.


 * Barrett's esophagus: Barrett's esophagus is a condition in which the squamous cells that usually line the esophagus are replaced with glandular cells when reflux of stomach acid into the lower esophagus continues for a long period of time.


 * Achalasia: Is a disease in which the muscle at the lower end of the esophagus does not relax properly. As the result, food has trouble in passing into the stomach and tends to collect in the esophagus and the esophagus above this muscle becomes dilated. People with achalasia have a risk of esophageal cancer that is at least 15 times normal.


 * Stomach bacteria: Epidemiological surveys demonstrate patients treated to get rid of H. pylori get adenocarcinoma of the esophagus more often than expected.


 * Injury to the esophagus: Chemical such as lye may cause a severe chemical burn in the esophagus. The scar tissue can make esophagus very narrow after the injury heals. People with these narrow esophageal passages have a high rate of the squamous cell type of esophageal cancer after several years.


 * Workplace exposures: Clinical surveys show exposure to chemical fumes such as solvents used for dry cleaning may lead to an increased risk of esophageal cancer.


 * Tobacco and alcohol


 * Diet: About 15% of esophageal cancer can be linked to a diet poor in fruits and vegetables.


 * Obesity


 * Gender: Men have a 3-fold higher rate of esophageal cancer than women.


 * Age: Most cases occur in those 65 and older.

When to seek urgent medical care?
Call your health care provider if symptoms of esophageal cancer develop. If experience one or many of the following symptoms you should seek urgent medical care as soon as possible:


 * Severe dysphagia: Esophageal cancer causes problems swallowing and eventually may prevent patients from being able to swallow at all. You need to see the doctor to obtain nutritional support.


 * Vomiting a large amount of blood: This is the result of cancer invading the vessels of esophageal wall. If blood loss is abundant enough it

Diagnosis
It is hard to diagnose esophageal cancer in its early stages. Other problems can also cause the same symptoms such as stomach discomfort, indigestion swallowing and gastroesophageal reflux disease (GERD). So, if you have those symptoms, you had better go to see your doctor to do some tests. They include lab tests, image tests and endoscopy.


 * Upper endoscopy and biopsy: This is the main test used to diagnose esophageal cancer when people have certain risk factors or when signs and symptoms suggest this disease may be present. After you are sedated (made sleepy), an endoscope which is a thin, flexible, lighted tube is passed down your throat. Then the doctor can view the lining of your esophagus and other digestive tracts. If abnormal areas are noted, biopsies (tissue samples) can be obtained through the endoscope. The tissue samples will be checked by the pathologists under a microscope to see whether cancer is present or not.


 * Barium swallow: This is an x-ray test during which a person is given an injection of a medication that will temporarily slow any bowel movements, so structures can be more easily seen on the x-rays. For this test, the patient drinks a millkshake-like substance called barium. X-ray method called fluroscopy tracks how the barium moves through your esophagus and other digestive tracts such as the stomach, and small intestine. Pictures are taken in a variety of positions.


 * Computed tomography (CT) scan: CT scans are often used to diagnose esophageal cancer. It can confirm the location of the cancer and show the organs near the esophagus, as well as lymph nodes and distant organs where the cancer might have spread. These are helpful in staging the cancer and in determining whether surgery is a good treatment option.


 * Magnetic resonance imaging (MRI): An MRI uses magnetic fields and is a different imaging type than computed tomography (CT) which produces detailed images of the body. Like computed tomography (CT), a contrast agent may be injected into a patient’s vein to create a better picture. MRI scans take longer to perform than CT scans.


 * Positron emission tomography (PET) scan: When doing this test, a small amount of a radioactive medium is injected into your body and absorbed by the organs or tissues. This radioactive substance gives off energy which creates the images. PET scans can provide more helpful information than CT or MRI scans. It is used to see if the cancer has spread to the lymph nodes and also useful for your doctor to locate where the cancer has spread.

Treatment options
Patients with esophageal cancer have many treatment options. The selection depends on the size and stage of the tumor. The options are surgery, radiation therapy, chemotherapy, or a combination of methods and palliative treatment.

Surgery: It includes the following methods:


 * Esophagectomy


 * Different methods of esophagectomy


 * Open esophagectomy


 * Minimally invasive esophagectomy

Radiation therapy: This is a cancer treatment that kills cancer cells or keeps them from growing by using high-energy x-rays or other types of radiation.

Chemotherapy: This treatment uses drugs to stop the growth of cancer cells either by killing the cells or by stopping them from dividing.

Photodynamic therapy (PDT)

Laser ablation 

Radiofrequency ablation (RFA)

Argon plasma coagulation 

Electrocoagulation 

Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects may not be the same for each person, and they may change from one treatment session to the next.

Diseases with similar symptoms
Other health problems may also cause similar symptoms. Go to see your doctor to verify your diseases as early as possible. Diseases with similar symptoms are listed below:


 * Gastroesophageal reflux disease (GERD)


 * Barrett's esophagus


 * Esophageal achalasia


 * Stomach gastritis, gastric ulcer and stomach cancer


 * Lung cancer


 * Depression

Where to find medical care for Esophageal cancer?
Directions to Hospitals Treating esophageal cancer

Prevention of Esophageal cancer
Epidemiology data shows the following intervention may help to reduce your risk of esophageal cancer:


 * Treating gastroesophageal reflux disease (GERD) and Barrett's esophagus early


 * Prevention of injury to the esophagus


 * Prevention of exposure to chemical fumes


 * Avoidance of tobacco and alcohol


 * Diet: Have a healthy diet rich in fruits and vegetables.


 * Avoid obesity

What to expect (Outlook/Prognosis)?
The prognosis of esophageal cancer depends on the following:


 * The size and location of the tumor


 * The stage of the cancer: Whether it affects part of the esophagus, invades the whole esophagus, or has spread to other places in the body.


 * The patient’s general health