Oesophageal Cancer

Oesophageal cancer is a type of cancer that originates in the oesophagus, the muscular tube responsible for transporting food and liquid from the throat to the stomach. This cancer occurs when malignant cells form in the tissues of the oesophagus, leading to the development of a tumour. It is important to note that oesophageal cancer can start at any point along the length of the oesophagus. In this article, we will discuss the stages, types, and risk factors associated with oesophageal cancer.

What is Oesophageal Cancer?

Oesophageal cancer is a type of malignancy that arises in the oesophagus, the muscular tube that connects the throat to the stomach. It occurs when cancer cells develop in the inner layer of the oesophagus and can spread throughout the other layers and to other parts of the body (metastasis). There are two main types of oesophageal cancer: squamous cell carcinoma, which originates from the squamous cells lining the inner oesophagus, and adenocarcinoma, which develops from gland cells, typically in the lower oesophagus near the stomach. Understanding the stages of oesophageal cancer is essential for determining the appropriate treatment and prognosis.

Oesophageal cancer is primarily classified into two types based on the specific cells involved in the development of the tumour. These types are:

• Squamous cell carcinoma: This type of oesophageal cancer arises from the squamous cells that line the inner surface of the oesophagus. It is most commonly found in the upper or middle parts of the oesophagus and is strongly associated with heavy alcohol consumption and smoking.

• Adenocarcinoma: This type of oesophageal cancer develops from the gland cells in the oesophagus, particularly in the lower portion near the stomach. It is associated with Barrett's oesophagus and gastro-oesophageal reflux disease (GERD).

The early signs of oesophageal cancer include:

• Difficulty swallowing (dysphagia)

• Chest pain or discomfort

• Unintended weight loss

• Vocal hoarseness or persistent coughing

Oesophageal cancer symptoms often remain unnoticeable until the cancer reaches an advanced stage. As the disease progresses, individuals may experience:

• Trouble swallowing: Difficulty swallowing solid foods, liquids, or even saliva can lead to choking or an inability to swallow.

• Chronic chest pain: Pain in the middle of the chest that worsens over time, especially when swallowing, is a common symptom.

• Weight loss: Unexplained weight loss due to reduced appetite or difficulty eating may occur.

• Persistent coughing or hoarseness: Developing a hoarse voice or a cough that doesn't improve can be signs of oesophageal cancer.

• Other symptoms: Vomiting, bone pain, and bleeding into the oesophagus, which can cause black stool and anaemia, may also be present.

The staging of oesophageal cancer is a critical aspect of determining the appropriate treatment plan and assessing the prognosis for patients. These include:

• Stage 0: In this stage, abnormal cells (not yet cancerous) are found only in the layer of cells lining the oesophagus. This stage is often detected during routine biopsies in individuals with Barrett's oesophagus.

• Stage I: Cancer cells are confined to the layer of cells lining the oesophagus and have not spread further.

• Stage II: The cancer has reached the muscle layer or the outer wall of the oesophagus. It may have also spread to one or two nearby lymph nodes.

• Stage III: The cancer has penetrated deeper into the inner muscle layer or the connective tissue wall. It may have spread beyond the oesophagus to surrounding organs and/or more lymph nodes near the oesophagus.

• Stage IV: This is the most advanced stage, where the cancer has metastasised to other organs in the body and/or to lymph nodes far from the oesophagus.

Oesophageal cancer develops when mutations occur in the DNA of cells in the oesophagus, leading to uncontrolled cell growth. Several factors can increase the risk of developing this type of cancer:

• Chronic heartburn or acid reflux: Conditions like gastro-esophageal reflux disease (GERD) can cause damage to the lining of the oesophagus over time.

• Barrett's oesophagus: This condition, which develops in some people with GERD, increases the risk of adenocarcinoma, a type of oesophageal cancer.

• Smoking and heavy alcohol consumption: Both habits are closely associated with the development of squamous cell carcinoma, another form of oesophageal cancer.

• Achalasia: This rare disorder affecting the muscles in the lower oesophagus can increase the risk of squamous cell carcinoma.

While oesophageal cancer can affect anyone, certain factors can elevate the risk of developing this condition:

• Older age, typically over 55 years

• Male gender

• Obesity

• Smoking and heavy alcohol use

• A diet low in fruits and vegetables

• Chronic acid reflux and Barrett's oesophagus

• Achalasia, a condition that affects the muscles of the oesophagus

Who's at Risk?

Certain groups of people may be at a higher risk of developing oesophageal cancer:

• People with chronic acid reflux or GERD

• Individuals with Barrett's oesophagus

• Smokers and heavy alcohol drinkers

• Those with achalasia

• Older adults, particularly those over 55 years old

• Men

• People who are overweight or obese

• Individuals with a diet low in fruits and vegetables and high in processed meats

• Those who have undergone previous radiation therapy to the chest or upper abdomen

Oesophageal cancer and its treatment can lead to several complications that significantly impact the patient's quality of life and survival. Some of the postoperative complications include:

• Anastomotic leak: A serious complication where a leak occurs at the junction of the oesophagus and the stomach or bowel, which can lead to mediastinitis, sepsis, and requires immediate treatment.

• Breathlessness and chest infections: Patients may experience breathlessness and are at risk of chest infections, including pneumonia.

• Heart problems: Surgery can lead to heart complications, which may affect other organs such as the kidneys.

• Voice changes: Damage to the nerve connecting to the voice box can result in voice changes, including hoarseness, which is usually temporary but can be permanent in some cases.

• Functional gastric emptying disorder: Some patients may experience gastric emptying disorders due to the resection of part of the stomach, leading to delayed emptying of stomach contents.

• Eating problems and weight loss: Many patients experience difficulties eating, leading to weight loss, which may necessitate a feeding tube and dietary adjustments.

Other complications of oesophageal cancer include obstruction, where the tumour can obstruct the oesophagus, making swallowing difficult; aspiration, where food or liquid enters the airway; and reflux, where surgery can cause gastro-esophageal reflux, leading to symptoms like heartburn.

Certain lifestyle changes can significantly reduce the risk of developing this condition. Some of the key steps for oesophageal cancer prevention include:

• Maintaining a healthy weight: Being overweight or obese increases the risk of oesophageal cancer, particularly adenocarcinoma.

• Eating a balanced diet: A diet rich in fruits, vegetables, and whole grains may help reduce the risk of oesophageal cancer.

• Limiting alcohol consumption: Excessive alcohol intake is a significant risk factor for oesophageal cancer, especially squamous cell carcinoma.

• Quitting smoking: Smoking is a major risk factor for both types of oesophageal cancer, and quitting can significantly reduce the risk.

• Managing acid reflux: Chronic acid reflux, or gastro-esophageal reflux disease (GERD), can increase the risk of oesophageal adenocarcinoma. Treating GERD with lifestyle changes and medication can help prevent the development of Barrett's oesophagus, a precancerous condition.

• Screening for Barrett's oesophagus: People with chronic GERD or other risk factors may benefit from regular screening for Barrett's oesophagus, which can help detect precancerous changes early.

The following diagnostic tests and procedures are commonly used to diagnose oesophageal cancer:

• Medical history and physical examination: The doctor will ask about symptoms, risk factors, and family history of oesophageal cancer. They will also perform a physical examination to check for signs of the disease, such as lymph node enlargement or abdominal masses.

• Barium swallow: The patient swallows a liquid containing barium, which coats the oesophagus and allows for clear X-ray images of the organ. This can help identify any abnormalities or tumours.

• Endoscopy: A thin, flexible tube with a light and camera (endoscope) is inserted through the mouth and down the throat to examine the oesophagus. The doctor may take tissue samples (biopsy) during the procedure for further analysis.

• Biopsy: A small sample of suspicious tissue is removed and examined under a microscope to determine if cancer cells are present. This can be done during an endoscopy or through a needle guided by an imaging test.

• Imaging tests: Computed tomography (CT) scans, positron emission tomography (PET) scans, and magnetic resonance imaging (MRI) can help determine the extent of the cancer and whether it has spread to other parts of the body.

• Endoscopic ultrasound (EUS): This procedure combines endoscopy and ultrasound to provide detailed images of the oesophagus and surrounding structures. It can help determine the depth of tumour invasion and involvement of nearby lymph nodes.

The management of oesophageal cancer involves a multidisciplinary approach tailored to the stage and type of the cancer. The treatment options may include:

• Surgery: For early-stage oesophageal cancer, endoscopic mucosal resection (EMR) or oesophagectomy may be performed.

• Chemotherapy: Used alone or in combination with other treatments, chemotherapy can be given before surgery (neoadjuvant), after surgery (adjuvant), or to relieve symptoms in advanced cases (palliative).

• Radiation therapy: Radiation can be used alone or combined with chemotherapy (chemoradiation) for unresectable tumours or before surgery.

• Immunotherapy: Checkpoint inhibitors like pembrolizumab and nivolumab may be used for tumours with high PD-L1 expression or high microsatellite instability (MSI-H) status.

• Targeted therapy: Trastuzumab can be added to chemotherapy for HER2-positive tumours.

• Palliative care: Interventions such as endoscopic stenting, intraluminal brachytherapy, and supportive care help manage symptoms and improve quality of life in advanced cases.

The stage of oesophageal cancer is a key determinant of the treatment approach:

• Stage 0: Usually treated with surgery or endoscopic resection.

• Stage I: Chemoradiotherapy followed by surgery, or surgery alone.

• Stage II: Chemoradiotherapy followed by surgery is preferred, but surgery alone or chemotherapy followed by surgery are also options.

• Stage III: Chemoradiotherapy followed by surgery is standard. Preoperative chemotherapy followed by surgery or definitive chemoradiotherapy are alternatives.

• Stage IV: Chemoradiotherapy followed by surgery may be considered if metastases are limited. Otherwise, systemic therapy with chemotherapy, immunotherapy, or targeted therapy is the mainstay.

Medications for Oesophageal Cancer

Several types of medications are used in the treatment of oesophageal cancer:

• Chemotherapy agents: These include 5-fluorouracil (5-FU), capecitabine, cisplatin, oxaliplatin, paclitaxel, and docetaxel, among others. They are often used in combination regimens.

• Immunotherapy medications: Pembrolizumab and nivolumab are checkpoint inhibitors that help the immune system fight cancer cells. They are used in select patients based on biomarker testing.

• Targeted therapy: Trastuzumab is a monoclonal antibody used in HER2-positive oesophageal adenocarcinoma. Ramucirumab, a VEGFR-2 inhibitor, may be used in the second-line setting.

These medications may be used alone or in combination, depending on the stage and molecular characteristics of the tumour.

It is essential to consult a doctor if you experience any symptoms suggestive of oesophageal cancer, such as difficulty swallowing (dysphagia), unintentional weight loss, chest pain, hoarseness, or chronic cough and bleeding (vomiting blood or passing blood in stools). Early detection and prompt treatment can significantly improve the prognosis of oesophageal cancer.

• Oesophageal cancer is a malignant tumour that develops in the oesophagus, the tube connecting the throat to the stomach.

• The two main types of oesophageal cancer are adenocarcinoma and squamous cell carcinoma.

• Risk factors for oesophageal cancer include chronic acid reflux, smoking, alcohol abuse, obesity, and a diet low in fruits and vegetables.

• Symptoms of oesophageal cancer may include difficulty swallowing, weight loss, chest pain, hoarseness, and chronic cough.

• Diagnosis of oesophageal cancer involves endoscopy, biopsy, and imaging tests like CT, PET, and endoscopic ultrasound.

• Treatment for oesophageal cancer depends on the stage and type of the cancer and may include surgery, chemotherapy, radiation therapy, immunotherapy, and targeted therapy.

• Early detection and treatment of oesophageal cancer can significantly improve outcomes and survival rates.