What is Esophageal Cancer?
Most cancers of the esophagus, the tube connecting your throat to your stomach, are classified into two types: squamous cell carcinoma (SCC) and adenocarcinoma (ADCA). Squamous cell carcinoma is a type of cancer that forms in the cells that line the esophagus, while adenocarcinoma is a cancer that begins in cells that make and release mucus and other fluids.
In the past 30 years, in the United States, there has been a decline (less than 30%) in squamous cell carcinoma cases while adenocarcinoma has been increasing (more than 60%). Furthermore, adenocarcinoma is becoming more common in the lower part of the esophagus and the area where the esophagus meets the stomach, known as the gastroesophageal junction (GEJ).
This rise is linked to Barrett’s esophagus, a condition where the normal cells lining your esophagus become replaced with cells similar to the lining of your stomach. This cell change increases your risk of developing esophageal cancer.
What Causes Esophageal Cancer?
Almost 90% of cases of a type of throat cancer called “esophageal squamous cell carcinoma,” found in the U.S., are due to smoking, consuming alcohol, and eating a diet low in fruits and vegetables. In developing countries, the reasons for this kind of throat cancer are less clear but may be related to poor nutrition, low fruit and vegetable intake, and drinking hot beverages. Infection with the human papillomavirus (HPV) has been linked with more throat cancers affecting the upper part of the esophagus, which is part of the throat.
Certain pre-existing conditions – like achalasia which affects the ability to swallow, caustic strictures which are scar tissues in the throat, gastrectomy which is the removal of all or part of the stomach, and atrophic gastritis which is stomach inflammation – are all linked with a higher risk of getting esophageal squamous cell carcinoma.
If a person has or had another throat cancer called “squamous cell carcinoma” in their digestive tract, they might also be at risk to develop the same type of cancer in their esophagus. There is a rare hereditary condition called Tylosis (or Howel-Evans syndrome), which involves skin thickening, that is strongly linked to this type of throat cancer and carries a 40%-90% risk of developing cancer by age 70.
There’s also a rare genetic disorder called Bloom syndrome, which increases the likelihood of getting leukemia, lymphomas, and Wilms tumor (which is a kidney cancer), this syndrome may bring about esophageal squamous cell carcinoma at an early age.
Another hereditary disorder called Fanconi anemia, characterized by birth defects, low blood cell counts, and a higher risk of blood cancers, also plays a role in increasing the risk of esophageal squamous cell carcinoma.
The use of a class of drugs called oral bisphosphonates has been related to this throat cancer and another type called adenocarcinoma in post-market surveillance studies.
As for esophageal adenocarcinomas – another type of throat cancer, around 80% of these cases in the U.S. are linked to smoking, obesity, acid reflux (GERD), and a diet low in fruits and vegetables. Habitual alcohol consumption has not been associated with this throat cancer.
Certain genetic variations and conditions that increase acid exposure to the esophagus, including a disease called Barrett esophagus, might play a role in causing this cancer.
Having a high fiber diet, antioxidants, fruits and vegetables, folate, vitamin C, acid-blocking medications (proton-pump inhibitors), and non-steroidal anti-inflammatory drugs (NSAIDs) can potentially help protect against developing Barrett esophagus and, as a result, esophageal adenocarcinoma. However, none of these are confirmed as a preventive treatment.
Risk Factors and Frequency for Esophageal Cancer
In the US, esophageal cancers are the fifth most common gastrointestinal cancer, and the sixth most common globally. Each year, around 16,940 cases are reported in America. There’s an area known as the “esophageal cancer belt” that spans parts of northern Iran, southern Russia, central Asian countries, and northern China. Here, up to 90% of all cancer cases are squamous cell cancers. In these regions, esophageal cancer is the fourth most common cancer.
However, the United States is lower-risk. Still, we are seeing a rise in esophageal adenocarcinoma cases, largely due to an increase in obesity and GERD. On a positive note, there’s been a steady drop in squamous cell carcinoma instances due to long-term decreases in using tobacco and drinking alcohol. Adenocarcinoma is especially common in white males, while esophageal squamous cell carcinoma mainly affects black and Asian populations.
Signs and Symptoms of Esophageal Cancer
Both esophageal adenocarcinoma and squamous cell carcinoma, two types of esophageal cancer, usually cause problems with eating solid food. This happens as the disease progresses, leading to blockages in the esophagus. As the condition worsens, they might also have difficulty swallowing liquids. Weight loss and weakness are often result because of the difficulties with eating. Additionally, individuals may experience a burning sensation or discomfort in the area behind the breastbone.
- Difficulty swallowing solid food, progressing to liquids
- Weight loss
- Feeling weak or tired
- Discomfort or burning in the chest area
Some other symptoms like vomiting blood, passing black stools, or signs of anemia can also be present because of bleeding in the gastrointestinal tract. Some patients might also bring food back up into the mouth (known as regurgitation). On rare occasions, those affected by esophageal cancer might get aspiration pneumonia, caused by breathing food, stomach acid, or saliva into the lungs. If the cancer spreads to the tracheobronchial wall and causes fistulas (abnormal connections between the esophagus and airways), it may lead to voice changes, cough, or a type of pneumonia that occurs when a blockage in the airways causes fluid to collect in the lungs.
- Vomiting blood
- Black stools
- Anemia (due to bleeding)
- Regurgitation of food
- Aspiration pneumonia (rare)
- Changes in voice, cough, post-obstructive pneumonia (if cancer spreads to tracheobronchial wall)
Testing for Esophageal Cancer
Your doctor will initially examine lymph nodes in specific areas of your body like the upper chest (supraclavicular region) and underarm (axillary region), as part of the routine check-up. If the doctor suspects a certain disease, they might choose to start with a barium study, this is a test that allows them to look at your digestive system. However, to confirm a disease, an upper endoscopy is typically performed. In this procedure, a tiny camera attached to a thin tube is inserted down the throat to see the upper part of your digestive system. Small tissue samples (biopsies) are often taken during this process to study them under a microscope, which aids in making a precise diagnosis.
Getting multiple biopsies can improve the chances of getting an accurate diagnosis. Staining the tissue samples with Lugol’s iodine, a special dye, to see details isn’t a standard procedure and not usually done.
A CT scan of the chest and abdomen might also be ordered. This x-ray test creates detailed cross-sectional images of your body and helps your doctor to understand the extent of the disease. It can also detect if it has spread to the liver and surrounding lymph nodes. However, CT scans might not always be accurate in telling how deep a tumor is, or in recognizing small disease spread, particularly within the lining of your abdominal cavity.
Endoscopic ultrasound (EUS) is a procedure that’s often used to give a more detailed look at the disease spread within the area. It’s highly accurate in assessing the spread and involvement of nearby lymph nodes. It also allows doctors to get tissue samples from lymph nodes that look abnormal. However, this procedure has its limitations, as it may underestimate disease size in one-third of cases.
To check for disease spread to distant parts of the body, a PET/CT scan is commonly used. It helps detect hidden disease locations and essentially, helps the doctor decide how aggressively to treat it. One study suggested that if the disease has spread to distant parts, aggressive local treatments may not be needed in one-fifth of cases.
The use of diagnostic laparoscopy, a surgical procedure that involves a small cut and camera to look inside your abdomen, is debated over and not routinely recommended. Tumors are classified according to a system called TNM staging, which takes into consideration the size of the tumor, whether or not it has spread to the lymph nodes, and if it has spread to distant parts of the body. These factors can significantly determine the treatment plan for the patient.
Your doctor will continue to utilize a combination of these techniques to provide the most accurate diagnosis and staging which in turn guides the best treatment option for you.
Treatment Options for Esophageal Cancer
Accurate staging of your cancer before surgery will help your doctor determine the most suitable treatment for you.
Here’s a simplified explanation of the general recommendations:
1. If the cancer is superficial and limited, which we refer to as less than T1a, it can be removed by a scope-based procedure.
2. If the cancer has penetrated the layer beneath the surface of the organ or has spread to the lymph nodes, which we refer to as more than T1b, it will need to be surgically removed along with the nearby lymph nodes.
3. If the cancerous lesion is operable, and it has invaded the muscle layer of the organ and has spread to your lymph nodes, it’s classified as less than T2N1. You will be given chemoradiation therapy before surgery.
4. If the cancer is advanced or has spread to other parts of your body, you will receive palliative systemic therapy, which is aimed at relieving symptoms and improving the quality of life, but is not a cure.
When it comes to the treatment methods:
– Endoscopic Resection is a procedure where your doctor uses a long, flexible tube (an endoscope) to remove small pieces of tissue from your body. This is usually done in specialized centres and is suitable only if the cancer is at the superficial stage. It’s important to have close follow-ups after this procedure.
– Surgical Resection is where the cancer is removed during a surgery. This is the main treatment for localized esophageal cancers.
– Neoadjuvant Therapy is the treatment given before the main treatment (which is usually surgery). This could be chemotherapy, radiation therapy, or both. This helps in reducing the size of the cancerous lesion so that it can be removed more effectively during surgery.
– Adjuvant Therapy is the treatment given after the main treatment to kill any remaining cancer cells in your body.
– Systemic Treatment is where drugs are used to kill cancer cells throughout your body. This could be chemotherapy, radiotherapy, or targeted drug therapies.
Each treatment plan comes with its own set of benefits and risks, and patients may respond differently to each treatment. Your doctor will consider your overall health, the type and stage of your cancer, your personal preferences, and other factors when recommending a treatment plan for you.
What else can Esophageal Cancer be?
There are various conditions that can affect your esophagus, causing difficulties in swallowing and other issues. Some of these conditions include:
- Achalasia – a condition where the esophagus is unable to move food into the stomach
- Esophageal stricture – a narrowing of the esophagus that makes it hard to swallow
- Esophageal leiomyoma – a benign tumor made up of smooth muscles, most commonly found in the esophagus
Possible Complications When Diagnosed with Esophageal Cancer
Apart from cancer, patients may experience issues arising from surgery, radiation treatment, and chemotherapy.
Potential Complications:
- Issues related to surgery
- Complications from radiation treatment
- Side effects of chemotherapy
Recovery from Esophageal Cancer
Typically, patients who have had surgery need about 2 to 3 weeks for recovery. These patients often receive their meals through a jejunostomy tube (a tube that places nutrition directly into the small intestine). It’s unfortunate, but a lot of these patients aren’t able to return home straight away because they still struggle with their everyday activities. So, they usually move to a skilled nursing facility, where healthcare professionals can assist them until they regain strength.
Preventing Esophageal Cancer
To best manage your health, quitting smoking is highly recommended. It’s also crucial to avoid consuming alcohol. Following a healthy diet full of nutritious foods and maintaining a balanced lifestyle can also contribute substantially to your wellbeing. If you have GERD (Gastroesophageal Reflux Disease), which is a digestive disorder that affects the ring of muscle between your esophagus and stomach and leads to acid reflux, make sure it is appropriately treated to avoid further complications.
