Pathology of esophageal cancer
Cancer that begins in the esophagus (also called esophageal cancer) is divided into two major types, squamous cell carcinoma and adenocarcinoma, depending on the type of cells that are malignant. Squamous cell carcinomas arise in squamous cells that line the esophagus. These cancers usually occur in the upper and middle part of the esophagus. Adenocarcinomas usually develop in the glandular tissue in the lower part of the esophagus. The treatment is similar for both types of esophageal cancer.
If the cancer spreads outside the esophagus, it often goes to the lymph nodes first. (Lymph nodes are small, bean-shaped structures that are part of the body's immune system.) Esophageal cancer can also spread to almost any other part of the body, including the liver, lungs, brain, and bones.
Risk Factors of esophageal cancer
The exact causes of cancer of the esophagus are not known. However, studies show that any of the following factors can increase the risk of developing esophageal cancer:
- Age. Esophageal cancer is more likely to occur as people get older; most people who develop esophageal cancer are over age 60.
- Sex. Cancer of the esophagus is more common in men than in women.
- Tobacco Use. Smoking cigarettes or using smokeless tobacco is one of the major risk factors for esophageal cancer.
- Alcohol Use. Chronic and/or heavy use of alcohol is another major risk factor for esophageal cancer. People who use both alcohol and tobacco have an especially high risk of esophageal cancer. Scientists believe that these substances increase each other's harmful effects.
- Barrett's Esophagus. Long-term irritation can increase the risk of esophageal cancer. Tissues at the bottom of the esophagus can become irritated if stomach acid frequently "backs up" into the esophagus -- a problem called gastric reflux. Over time, cells in the irritated part of the esophagus may change and begin to resemble the cells that line the stomach. This condition, known as Barrett's esophagus, is a premalignant condition that may develop into adenocarcinoma of the esophagus.
- Other Types of Irritation. Other causes of significant irritation or damage to the lining of the esophagus, such as swallowing lye or other caustic substances, can increase the risk of developing esophageal cancer.
- Medical History. Patients who have had other head and neck cancers have an increased chance of developing a second cancer in the head and neck area, including esophageal cancer.
Symptoms of esophageal cancer
Early esophageal cancer usually does not cause symptoms. However, as the cancer grows, symptoms may include:
- Difficult or painful swallowing
- Severe weight loss
- Pain in the throat or back, behind the breastbone or between the shoulder blades
- Hoarseness or chronic cough
- Coughing up blood
These symptoms may be caused by esophageal cancer or by other conditions. It is important to check with a doctor.
Diagnosing Esophageal Cancer
To help find the cause of symptoms, the doctor evaluates a person's medical history and performs a physical exam. The doctor usually orders a chest x-ray and other diagnostic tests. These tests may include the following:
A barium swallow (also called an esophagram) is a series of x-rays of the esophagus. The patient drinks a liquid containing barium, which coats the inside of the esophagus. The barium makes any changes in the shape of the esophagus show up on the x-rays.
Esophagoscopy (also called endoscopy) is an examination of the inside of the esophagus using a thin lighted tube called an endoscope. An anesthetic (substance that causes loss of feeling or awareness) is usually used during this procedure. If an abnormal area is found, the doctor can collect cells and tissue through the endoscope for examination under a microscope. This is called a biopsy. A biopsy can show cancer, tissue changes that may lead to cancer, or other conditions.
Staging the Disease
If the diagnosis is esophageal cancer, the doctor needs to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to what parts of the body. Knowing the stage of the disease helps the doctor plan treatment. Listed below are descriptions of the four stages of esophageal cancer.
- See staging system for esophageal cancer
Some tests used to determine whether the cancer has spread include:
- CAT (or CT) scan (computed tomography). A computer linked to an x-ray machine creates a series of detailed pictures of areas inside the body.
- Bone scan. This technique, which creates images of bones on a computer screen or on film, can show whether cancer has spread to the bones. A small amount of radioactive substance is injected into a vein; it travels through the bloodstream, and collects in the bones, especially in areas of abnormal bone growth. An instrument called a scanner measures the radioactivity levels in these areas.
- Bronchoscopy. The doctor puts a bronchoscope (a thin, lighted tube) into the mouth or nose and down through the windpipe to look into the breathing passages.
Treatment of esophageal cancer
Treatment for esophageal cancer depends on a number of factors, including the size, location, and extent of the tumor, and the general health of the patient. Patients are often treated by a team of specialists, which may include a gastroenterologist (a doctor who specializes in diagnosing and treating disorders of the digestive system), surgeon (a doctor who specializes in removing or repairing parts of the body), medical oncologist (a doctor who specializes in treating cancer), and radiation oncologist (a doctor who specializes in using radiation to treat cancer). Because cancer treatment may make the mouth sensitive and at risk for infection, doctors often advise patients with esophageal cancer to see a dentist for a dental exam and treatment before cancer treatment begins.
Many different treatments and combinations of treatments may be used to control the cancer and/or to improve the patient's quality of life by reducing symptoms.
Surgery is the most common treatment for esophageal cancer. Usually, the surgeon removes the tumor along with all or a portion of the esophagus, nearby lymph nodes, and other tissue in the area. (An operation to remove the esophagus is called an esophagectomy.) The surgeon connects the remaining healthy part of the esophagus to the stomach so the patient is still able to swallow. Sometimes, a plastic tube or part of the intestine is used to make the connection. The surgeon may also widen the opening between the stomach and the small intestine to allow stomach contents to pass more easily into the small intestine. Sometimes surgery is done after other treatment is finished.
Radiation therapy, also called radiotherapy, involves the use of high-energy rays to kill cancer cells. Radiation therapy affects cancer cells in the treated area only. The radiation may come from a machine outside the body (external radiation) or from radioactive materials placed in or near the tumor (internal radiation). A plastic tube may be inserted into the esophagus to keep it open during radiation therapy. This procedure is called intraluminal intubation and dilation. Radiation therapy may be used alone or combined with chemotherapy as primary treatment instead of surgery, especially if the size or location of the tumor would make an operation difficult. Doctors may also combine radiation therapy with chemotherapy to shrink the tumor before surgery. Even if the tumor cannot be removed by surgery or destroyed entirely by radiation therapy, radiation therapy can often help relieve pain and make swallowing easier
Chemotherapy is the use of anticancer drugs to kill cancer cells. The anticancer drugs used to treat esophageal cancer travel throughout the body. Anticancer drugs used to treat esophageal cancer are usually given by injection into a vein (IV). Chemotherapy may be combined with radiation therapy as primary treatment (instead of surgery) or to shrink the tumor before surgery.
Nutrition for Cancer Patients
Eating well during cancer treatment means getting enough calories and protein to control weight loss and maintain strength. Eating well often helps people with cancer feel better and have more energy.
However, many people with esophageal cancer find it hard to eat well because they have difficulty swallowing. Patients may not feel like eating if they are uncomfortable or tired. Also, the common side effects of treatment, such as poor appetite, nausea, vomiting, dry mouth, or mouth sores, can make eating difficult. Foods may taste different.
After surgery, patients may receive nutrients directly into a vein. (This way of getting nourishment into the body is called an IV.) Some may need a feeding tube (a flexible plastic tube that is passed through the nose to the stomach or through the mouth to the stomach) until they are able to eat on their own.
Patients with esophageal cancer are usually encouraged to eat several small meals and snacks throughout the day, rather than try to eat three large meals. When swallowing is difficult, many patients can still manage soft, bland foods moistened with sauces or gravies. Puddings, ice cream, and soups are nourishing and are usually easy to swallow. It may be helpful to use a blender to process solid foods. The doctor, dietitian, nutritionist, or other health care provider can advise patients about these and other ways to maintain a healthy diet.
The Importance of Follow up Care
Followup care after treatment for esophageal cancer is important to ensure that any changes in health are found. If the cancer returns or progresses or if a new cancer develops, it can be treated as soon as possible. Checkups may include physical exams, x-rays, or lab tests. Between scheduled appointments, patients should report any health problems to their doctor as soon as they appear.
Providing Emotional Support
Living with a serious disease is challenging. Apart from having to cope with the physical and medical challenges, people with cancer face many worries, feelings, and concerns that can make life difficult. They may find they need help coping with the emotional as well as the practical aspects of their disease. In fact, attention to the emotional burden of having cancer is often a part of a patient's treatment plan. The support of the health care team (doctors, nurses, social workers), support groups, and patient-to-patient networks can help people feel less isolated and distressed, and improve the quality of their lives. Cancer support groups provide a setting in which cancer patients can talk about living with cancer with others who may be having similar experiences. Patients may want to speak to a member of their health care team about finding a support group. Many also find useful information in NCI fact sheets and booklets, including Taking Time and Facing Forward.