Esophageal Cancer

Symptoms: Difficulty swallowing, chest pain, cough, unintentional weight loss, heartburn, indigestion, and a hoarse voice.

Risk Factors: Smoking, alcohol use, GERD, esophageal achalasia, obesity, radiation therapy, barrette’s esophagus.

Prevalence: Currently, 0.6 million people worldwide are diagnosed with ulcerative colitis. In India, the total number of individuals suffering from esophageal cancer is approximately 4.9%.

Severity: Severe.

Gender affected: Both male and female populations can get affected but more common in men.

Which doctor to consult: A general physician, gastroenterologist, oncologist.

Overview: 

Esophageal cancer is a disease where malignant (cancer) cells form in the tissues of the esophagus, the tube that connects the throat to the stomach. This type of cancer can cause symptoms such as difficulty swallowing, chest pain, cough, unintentional weight loss, heartburn, indigestion, and a hoarse voice.

The exact cause of oesophagal cancer is unknown, but it develops when cells in the esophagus undergo mutations that cause them to grow and divide uncontrollably. Risk factors for developing esophageal cancer include gastroesophageal reflux disease (GERD), smoking, Barrett’s esophagus, obesity, alcohol consumption, and undergoing radiation therapy.

Treatment options vary based on the stage of cancer, and proper diagnosis and may include chemotherapy, radiation therapy, targeted therapies, and sometimes surgery to remove the tumor. Diagnosis often involves endoscopy to view the esophagus, imaging tests like PET scans and ultrasounds to determine the stage and spread of cancer, and biopsies to examine tissue samples.

It’s important for anyone experiencing symptoms or who has risk factors for esophageal cancer to seek medical attention promptly for evaluation and potential treatment.

Types of Esophageal cancer:

Esophageal cancer primarily comes in two types, which are determined by the cells where the cancer begins:

Adenocarcinoma: This type starts in the glandular cells of the esophagus, which are not normally present in the lining. These cells can appear due to a condition called Barrett’s esophagus. Adenocarcinoma is more common in the lower part of the esophagus and the upper part of the stomach, and it’s the most prevalent form of esophageal cancer in the United States.

Squamous Cell Carcinoma: This cancer originates from the squamous cells that line the inside of the esophagus. It’s strongly associated with smoking and excessive alcohol consumption.

Other less common types of esophageal cancer include:

Small Cell Carcinoma: A rare type that begins in neuroendocrine cells, which are cells that release hormones in response to signals from nerves.

Sarcoma: A rare soft tissue tumor.

Melanoma: An uncommon type that is typically associated with skin cancer.

Each type of esophageal cancer may develop differently and require unique treatment approaches. It’s important for anyone experiencing symptoms or who has risk factors for esophageal cancer to seek medical attention promptly for evaluation and potential treatment.

Symptoms

The symptoms of esophageal cancer typically become more noticeable as the disease progresses. Common symptoms include:

• Difficulty swallowing (dysphagia): This can start as a feeling that food is stuck in the throat or chest and can progress to a point where it is difficult to swallow liquids.

• Chest pain, pressure, or burning: Discomfort in the chest area, not necessarily related to eating.

• Coughing or hoarseness: Changes in voice or persistent coughing can be a sign of esophageal cancer.

• Weight loss without trying: Unintentional weight loss is a common symptom of many types of cancer, including esophageal cancer.

• Worsening indigestion or heartburn: Persistent or worsening symptoms of indigestion or heartburn can be associated with oesophagal cancer.

• Vomiting: In some cases, esophageal cancer can cause vomiting.

• Bone pain: If the cancer has spread to the bones, it can cause pain in those areas.

• Bleeding into the esophagus: This can lead to black stools or anaemia, which can cause fatigue.

Remember, having these symptoms does not necessarily mean you have esophageal cancer, as they can be caused by other conditions. However, early diagnosis and treatment are crucial for the best outcomes.

Causes:

The causes of esophageal cancer involve a combination of genetic, environmental, and lifestyle factors. While the exact cause is not fully understood, several risk factors have been identified that may increase the likelihood of developing this type of cancer:

• Gastroesophageal reflux disease (GERD): Chronic reflux of stomach acid into the esophagus can lead to changes in the lining of the esophagus, such as Barrett’s esophagus, which can increase the risk of adenocarcinoma.
• Smoking: Tobacco use significantly increases the risk of squamous cell carcinoma of the esophagus.
• Alcohol consumption: Heavy drinking, especially when combined with smoking, raises the risk of esophageal cancer.
• Obesity: Excess body weight can increase the risk of esophageal cancer, particularly adenocarcinoma.
• Diet: A diet low in fruits and vegetables might increase the risk of esophageal cancer.
• Barrett’s esophagus: A condition where the tissue lining the esophagus changes due to chronic acid reflux, increasing the risk of adenocarcinoma.
• Radiation therapy: Previous radiation treatment to the chest or upper abdomen can increase the risk of esophageal cancer.

It’s important to note that having one or more of these risk factors does not mean that a person will develop esophageal cancer. However, these factors can contribute to the likelihood of its occurrence. If you have concerns about your risk of esophageal cancer, it’s advisable to discuss them with a healthcare provider. 

Risk factors:

The risk factors for esophageal cancer include a range of lifestyle choices, medical conditions, and other factors that can increase the likelihood of developing this disease. Here are some of the key risk factors:

• Tobacco use: Smoking cigarettes, cigars, or pipes, and using tobacco in other forms can significantly increase the risk of esophageal cancer.
• Barrett’s esophagus: This condition involves precancerous changes in the cells of the esophagus and is often related to chronic acid reflux.
• Obesity: Excess body weight, particularly when fat is carried around the abdomen, can increase the risk of esophageal cancer.
• Alcohol consumption: Heavy drinking, especially when combined with smoking, can greatly increase the risk.
• Biliary reflux: A condition where bile flows back into the esophagus from the stomach.
• Esophageal achalasia: A swallowing disorder where the esophagus does not contract properly.
• Radiation therapy: Exposure to radiation in the chest or upper abdomen as part of treatment for other conditions can increase the risk.
• Gastroesophageal reflux disease (GERD): Chronic acid reflux can damage the lining of the esophagus and increase the risk of adenocarcinoma.
• Consumption of very hot liquids: Regularly drinking very hot beverages can cause thermal injury to the esophagus.
• Low fruit and vegetable intake: A diet poor in nutrients and antioxidants can contribute to the development of esophageal cancer.

It’s important to note that having one or more of these risk factors does not mean a person will definitely develop esophageal cancer, but it does increase the chances. If you have concerns about your risk factors, it’s advisable to discuss them with a healthcare provider.

Complications:

Esophageal cancer can lead to several serious complications, particularly as the disease progresses. Some of the potential complications include:

• Obstruction of the Esophagus: As the tumor grows, it can narrow the esophagus, making it difficult for food and liquid to pass through, leading to malnutrition and dehydration.
• Pain: Advanced esophageal cancer can cause significant pain, especially if the tumor invades surrounding tissues or nerves.
• Bleeding in the Esophagus: The tumor can cause bleeding within the esophagus. While this may be gradual, it can also be sudden and severe, potentially leading to anemia.
• Tracheo-esophageal Fistulas: These are abnormal connections that form between the esophagus and the trachea (windpipe), which can cause coughing up blood and increase the risk of aspiration pneumonia.
• Anemia: Chronic bleeding from the esophagus can lead to anemia, characterized by fatigue and weakness.
• Weight Loss: Cancer can cause significant weight loss, known as cachexia, which is a state of physical wasting away due to the loss of muscle and fat tissue.
• Aspiration Pneumonia: This is a lung infection caused by inhaling food, stomach acid, or saliva into the lungs.
• Metastasis: Esophageal cancer can spread (metastasize) to nearby organs such as the lungs and liver, as well as to distant organs like the brain, bones, and adrenal glands.
• Invasion of Nearby Structures: The cancer can invade nearby structures like the recurrent laryngeal nerve, trachea, and pleural cavity, which can lead to additional symptoms and complications.

These complications can significantly impact quality of life and may require specific treatments in addition to the management of the cancer itself. 

Prevention:

Preventing esophageal cancer involves addressing the risk factors that can be controlled. Here are some strategies that may help reduce the risk:

• Quit Smoking: Tobacco use is a major risk factor for esophageal cancer, so quitting smoking can significantly reduce the risk.
• Limit Alcohol: Reducing alcohol consumption can decrease the risk of developing esophageal cancer.
• Healthy Diet: Eating a diet rich in fruits and vegetables may lower the risk of esophageal cancer.
• Maintain a Healthy Weight: Obesity is a known risk factor, so maintaining a healthy weight through diet and exercise can help reduce the risk.
• Manage GERD: If you have gastroesophageal reflux disease, managing it with medication and lifestyle changes can reduce the risk of Barrett’s esophagus, a precursor to esophageal cancer.
• Regular Exercise: Staying physically active can help maintain a healthy weight and reduce the risk of esophageal cancer.

While these measures can help lower the risk, they do not guarantee prevention. It’s important to have regular medical check-ups, especially if you have risk factors for esophageal cancer.

When to visit a doctor:

It’s important to visit a general physician or oncologist or gastroenterologist if you experience any symptoms that could indicate esophageal cancer, especially if they persist. Some warning signs to watch for include:

• Difficulty swallowing (dysphagia)
• Unintentional weight loss
• Chest pain or discomfort
• Persistent cough or hoarseness
• Indigestion or heartburn that doesn’t improve with medication

Esophageal cancer is more treatable when caught early, so seeking medical attention promptly is crucial if you have these symptoms.

Diagnosis:

The diagnosis of esophageal cancer typically involves a combination of methods to confirm the presence of cancer and determine its stage. 

Esophageal cancer staging:

The TNM system is the main staging system in use, and it assesses: 

• T (Tumor): This represents the extent to which the tumor has spread to the surrounding tissue and the layers of the esophageal wall. 

• N (Lymph Nodes): It evaluates the proximity of the lymph nodes to the original tumor and whether or not cancer has spread to them.

• M (Metastasis): This evaluates if the cancer has progressed to other bodily regions.

The following stages of esophageal cancer are distinguished based on these criteria: 

• Stage 0 (carcinoma in situ): The upper layers of the esophagus contain abnormal cells that may eventually turn into cancer. 

• Stage 1: At this point, the esophagus thick muscle layer is the only area where cancer is present.

•  Stage 2: The cancer has spread to the esophagus's deeper layers and may have impacted neighboring lymph nodes.

• Stage 3: All esophageal layers contain cancer cells, and they may have also migrated to nearby organs.

• Stage 4: The cancer has spread to distant organs and lymph nodes, frequently the lungs and liver.

The diagnosis of esophageal cancer is a multi-step process that requires a combination of clinical evaluation, imaging, and laboratory tests. Here’s a detailed explanation of the diagnosis process for esophageal cancer:

1. Medical History and Physical Exam: 

A doctor will start by taking a thorough medical history to understand any symptoms and risk factors. A physical exam is conducted to look for signs of esophageal cancer and other health problems.

2. Endoscopy: 

This is a key diagnostic tool where a thin, flexible tube with a camera (endoscope) is passed down the throat to examine the esophagus. If suspicious areas are found, a biopsy can be performed during this procedure.

3. Biopsy: 

A biopsy involves taking a small sample of tissue from the esophagus. This sample is then examined under a microscope to look for cancer cells. It’s the definitive method for diagnosing esophageal cancer2.

4. Imaging Tests: 

Various imaging tests are used to help diagnose and stage esophageal cancer:

• Barium Swallow Study: A patient swallows a barium solution which coats the esophagus and shows up on X-rays, revealing abnormalities.
• CT Scan: Provides detailed cross-sectional images of the body to check for signs of cancer.
• MRI: Offers detailed images of soft tissues in the body.
• PET Scan: Detects the spread of cancer to other parts of the body.
• Endoscopic Ultrasound (EUS): Combines endoscopy and ultrasound to get detailed images of the esophageal wall and nearby lymph nodes.
• Bronchoscopy: Examines the inside of the airways for any spread of cancer.

5. Molecular Testing: 

This specialized approach involves testing the cancer cells for specific genes, proteins, and other factors unique to the tumor. It can help in choosing the best treatment options.

6. Symptom Evaluation: 

Identifying symptoms such as difficulty swallowing, weight loss, chest pain, or hoarseness can prompt further investigation for esophageal cancer.

If you suspect esophageal cancer, it’s important to consult a healthcare professional who can guide you through the necessary diagnostic procedures. Early detection is crucial for effective treatment and better outcomes.

Treatment:

Treatment for esophageal cancer can involve a combination of methods, including:

General treatment measures:

• Palliative Care: Aims to provide relief from symptoms and improve quality of life.
• Nutrition care: Malnutrition and dehydration can result from esophageal cancer's disruption of regular nutritional intake. Before treating the cancer itself, your treatment plan may include a phase of body fortification and recuperation.

Surgery

• Tumor excision: To remove small tumors confined to the superficial layers of the esophagus.
• Esophagectomy: Removal of a portion of the esophagus containing the tumor, with reconnection to the stomach.
• Esophagogastrectomy: Surgery to remove part of the esophagus and the upper portion of the stomach.
• Electrocoagulation: Using electric current to destroy cancer cells.

Chemotherapy

Medications like Carboplatin/Paclitaxel, Cisplatin/5-Fluorouracil (5-FU), Epirubicin/Cisplatin/5-FU (ECF), and Docetaxel/Cisplatin/5-FU (DCF) are used to kill cancer cells. Chemotherapy can be used at different times during treatment, often in combination with radiation therapy.

Radiation Therapy

High-powered energy from X-rays and protons is used to destroy cancer cells and shrink tumors.

• External-beam radiation therapy: The most common type of radiation therapy is called external-beam radiation therapy in which a machine emits radiation into the body.
• Internal radiation therapy: It is often known as brachytherapy, is the term used to describe radiation therapy administered through implants. The administration of a radioactive source close to the tumor is known as brachytherapy.

Targeted Therapy: 

Addresses specific molecules involved in cancer growth and spread. Some of the examples of targeted drugs used for esophageal cancer include

• Ramucirumab
• Trastuzumab

Immunotherapy:

Boosts the immune system’s response against cancer cells. Some of the examples of the immunotherapy drugs include:

• Nivolumab
• Pembrolizumab

Endoscopic treatment:

Endoscopic mucosal resection: For esophageal malignancies in their early stages and dysplasia (pre-cancer). It involves using tools inserted through the endoscope to remove aberrant tissue.

• Photodynamic treatment (PDT): It is used to treat advanced malignancies, dysplasia, Barrett's esophagus, and early-stage esophageal cancers. This treatment involves injecting a medication that builds up in cancer cells and is light-activated. During an endoscopy, the medication that kills cancer cells is activated by laser light.
• Radiofrequency ablation (RFA): It involves inserting an electrode-equipped balloon through endoscopy and using an electrical current to destroy aberrant cells. Over time, the treated area is replaced by normal cells.