MEDICAL CONDITIONS
Esophageal Cancer
(Cancer of the Esophagus)
What is the esophagus?
The esophagus, part of the digestive tract, is a tube that connects the throat with the stomach. It lies between the trachea (windpipe) and the spine. In an adult, the esophagus is about 10 inches long.
When a person swallows, the muscular walls of the esophagus contract to push food down into the stomach. Glands in the lining of the esophagus produce mucus, which keeps the passageway moist and makes swallowing easier.
The esophagus, like all other organs of the body, is made up of many types of cells. Normally, cells divide to produce more cells only when they are needed. This orderly process helps keep the body healthy.
What is cancer?
Cancer is a group of diseases with one thing in common; cells become abnormal, dividing too often and without any order.
When cells divide without control, they form too much tissue. The mass of extra tissue, called a tumor, can be benign or malignant.
Benign tumors are not cancer. They do not spread to other parts of the body and are seldom a threat to life. Benign tumors can usually be removed by surgery, and they are not likely to return.
Malignant tumors are cancer. They can invade and damage nearby healthy tissues and organs. Cancer cells can also break away from the tumor and enter the bloodstream or the lymphatic system. That is how cancer spreads and forms tumors in other parts of the body. The spread of cancer is called metastasis.
Cancer of the esophagus is also called esophageal cancer. Each year, about 11,000 Americans find out they have cancer of the esophagus. Cancer can develop in any part of the esophagus. If the cancer spreads outside the esophagus, it usually shows up in nearby lymph nodes (sometimes called lymph glands). In many cases, the cancer also spreads to the windpipe, the large blood vessels in the chest, and other nearby organs. Esophageal cancer can also spread to the lungs, liver, stomach, and other parts of the body.
Cancer that spreads is the same disease and has the same name as the original (primary) cancer. When cancer of the esophagus spreads, it is called metastatic esophageal cancer.
What causes cancer of the esophagus?
Cancer of the esophagus is fairly common in some parts of the world. But in the United States, this disease accounts for only about 1 percent of all cancers.
The exact causes of cancer of the esophagus are not known. Researchers are trying to solve this problem. The more they can find out about what causes this disease, the better the chance of finding ways to prevent it.
Studies in the United States show that esophageal cancer is found mainly in people over age 55. It affects men about twice as often as women, and it is more common in black people than in white people. Why one person gets esophageal cancer and another doesn't cannot be explained.
It is established that no one can "catch" esophageal cancer from another person. Cancer is not contagious.
Also, it is known that certain risk factors increase a person's chance of getting esophageal cancer. In the United States, smoking and excessive use of alcohol are the major risk factors for this disease. Heavy users of both alcohol and tobacco are much more likely to develop esophageal cancer than are people who do not drink or smoke.
Cutting down on the use of alcohol reduces the chance of getting esophageal cancer, as well as cancers of the mouth, throat, and larynx. By not smoking, people can lower their risk of cancers of the esophagus, lung, mouth, throat, larynx, bladder, and pancreas. Also, it is very important to know that people who develop cancer due to smoking are at risk of getting a second cancer. Most doctors urge esophageal cancer patients to stop smoking to cut down the risk of a new cancer and to reduce other problems, such as coughing.
The risk of cancer of the esophagus is also increased by long- term irritation of esophageal tissues. Tissue at the bottom of the esophagus can become irritated if the contents of the stomach frequently "back up" into the esophagus, a problem known as reflux. When cells in the irritated part of the esophagus change and begin to resemble the cells that line the stomach, doctors call this condition Barrett's esophagus. In some cases, Barrett's esophagus leads to esophageal cancer.
Other kinds of irritation or damage to the lining of the esophagus can also increase the risk of cancer. For example, people who have swallowed lye or other caustic substances have a higher-than-average risk because these substances damage esophageal tissue.
Poor nutrition is another factor that can increase a person's risk of esophageal cancer. Scientists are not sure exactly how diet changes the risk of developing this disease, but they think that it is important to have a well-balanced diet that includes generous amounts of fruits and vegetables.
Often, patients with esophageal cancer have no clear risk factors. In most cases, the disease is probably the result of several factors (known or unknown) acting together.
People who think they might be at increased risk for cancer of the esophagus should discuss this concern with their doctor. The doctor may be able to suggest ways to reduce the risk and can suggest an appropriate schedule of checkups.
What are symptoms of cancer of the esophagus?
Very small tumors in the esophagus usually do not cause symptoms. As the tumor grows, the most common symptom is difficulty in swallowing. The person may have a feeling of fullness, pressure, or burning as food goes down the esophagus. Also, it may feel as if food gets stuck behind the breastbone. Problems with swallowing may come and go. At first, they may be noticed mainly when the person eats meat, bread, or coarse foods, such as raw vegetables. As the tumor grows larger and the pathway to the stomach becomes narrower, other foods,even liquids, can be hard to swallow, and swallowing may be painful. Cancer of the esophagus can also cause indigestion, heartburn, vomiting, and frequent choking on food. Because of these problems, weight loss is common.
Sometimes a tumor in the esophagus causes coughing and hoarseness . It can also cause pain behind the breastbone or in the throat.
Any of these symptoms may be caused by cancer or by other, less serious health problems. People with symptoms like these often see a gastroenterologist, a doctor who specializes in diseases of the digestive tract.
How is cancer of the esophagus diagnosed?
To find the cause of any of these symptoms, the doctor asks about the patient's personal and family medical history and does a complete physical exam. In addition to checking general signs of health, the doctor usually orders x-rays and other tests.
An esophagram (also called a barium swallow) is a series of x- rays of the esophagus. To prepare for this test, the patient drinks a barium solution. The barium, which shows up on x-rays, coats the inside of the esophagus. The esophagram shows changes in the shape of the esophagus. The doctor can also use a special x-ray machine called a fluoroscope to watch the barium move down the esophagus to the stomach as the patient swallows.
Most patients also have a test called esophagoscopy. For this procedure, the patient's throat is sprayed with a local anesthetic to reduce discomfort and gagging. The doctor then passes a thin, flexible, lighted instrument called an endoscope through the mouth and down the throat into the esophagus. The scope lets the doctor see the lining of the esophagus and the place where the esophagus joins the stomach. If an abnormal area is found, the doctor does a biopsy (removal of a small amount of tissue through the endoscopy). Also, cells can be brushed or washed from the walls of the esophagus through the scope. A pathologist examines the samples under a microscope to see whether cancer is present.
If cancer is found, the pathologist can tell what type of cancer it is. Cancer that occurs in the middle or upper part of the esophagus is usually squamous cell carcinoma. When cancer develops at the lower end of the esophagus, near the stomach, it is usually adenocarcinoma. (Carcinoma is another name for cancer in the lining of tissues.)
If the pathologist finds esophageal cancer, the patient's doctor needs to know the stage, or extent, of the disease. Staging is a careful attempt to find out what parts of the body are affected by the cancer.
Treatment decisions depend on these findings. Staging usually involves a physical exam, with special attention to the neck and chest, blood tests, additional x-rays, and other tests. The results show whether the cancer is just in the esophagus or has spread.
The doctor usually order CT (or CAT) scans of the chest and upper abdomen. During a CT scan, many x-rays are taken and a computer combines them to create detailed pictures. Some patients also have an MRI scan, which produces pictures using a huge magnet linked to a computer.
The doctor uses special instruments to check the organs near the esophagus. For example, the doctor can look through a laryngoscope to see whether the cancer has spread to the larynx (voice box). A bronchoscope lets the doctor see into the trachea and bronchi (airways that lead into the lungs).
If lymph nodes near the esophagus are enlarged, the surgeon may perform a biopsy to find out whether they contain cancer cells. Sometimes, the surgeon also removes samples of other tissues in the area to see whether the cancer has spread.
How is cancer of the esophagus treated?
Treatment for esophageal cancer depends on a number of factors. Among these are the exact location, size, and extent of the tumor, and the type of cancer cells. The doctor also considers the person's age and general health to develop a treatment plan to fit each person's needs.
The patient's doctor may want to discuss the case with other doctors who treat cancer of the esophagus. Also, the patient may want to talk with the doctor about taking part in a research study of new treatment methods. Such studies, called clinical trials, are designed to improve cancer treatment.
Many patients want to learn all they can about their disease and their treatment choices so they can take an active part in decisions about their medical care. People with cancer have many questions and concerns about their health. The doctor is the best one to answer them. Most patients want to know the extent of their cancer, how it will be treated, how successful the treatment is likely to be, and how much it will cost.
Many people find it helpful to make a list of questions before they see the doctor. Taking notes can make it easier to remember what the doctor says. Some patients also find that it helps to have a family member or friend with them when they talk to the doctor, either to take part in the discussion or just to listen.
There is a lot to learn about cancer and its treatment. Patients should not feel that they need to understand everything the first time they hear it. They will have many chances to ask the doctor to explain things that are not clear.
TREATMENT METHODS
Cancer of the esophagus usually cannot be cured unless it is found in the earliest stages, before it has begun to spread. Unfortunately, early esophageal cancer causes few symptoms, and the disease is usually advanced when the diagnosis is made. However, advanced esophageal cancer can be treated and symptoms can be relieved.
Esophageal cancer is usually treated with surgery, radiation therapy (also called radiotherapy), or chemotherapy . The doctor may use just one treatment method or combine them, depending on the patient's needs.
In some cases, the patient is referred to doctors who specialize in different kinds of cancer treatment. Often, specialists work together as a team to plan and carry out the patient's care. The medical team may include a gastroenterologist, surgeon, oncologist (cancer specialist), radiation oncologist, nurse, dietitian, and social worker.
Surgery is often part of the treatment plan. Many patients with esophageal cancer have an operation called esophagectomy. Generally, the surgeon removes the tumor along with a portion of the esophagus, nearby lymph nodes, and other tissue in the area. Usually, it is possible to connect the stomach to the remaining part of the esophagus. In a few cases, the surgeon forms a new passageway from the throat to the stomach, using tissue from another part of the digestive tract (such as the colon) to replace the esophagus.
If a tumor blocks the esophagus but cannot be removed, the surgeon may be able to create a bypass, a new pathway to the stomach. In some cases, the surgeon can dilate (widen) the esophagus. This procedure may have to be repeated as the tumor grows. Sometimes, the doctor puts a tube into the esophagus to keep it open. Recently, some surgeons have used a laser to destroy cancerous tissue and relieve blockages.
Radiation therapy is the use of high-energy rays to damage cancer cells and stop them from growing. Like surgery, radiation therapy is local therapy; it affects cells only in the treated area. Radiation therapy can be used to shrink a tumor before surgery or to destroy cancer cells that may remain in the area after surgery. Radiation may also be used instead of surgery, especially if the size or location of the tumor would make an operation difficult. In some cases, radiation therapy is recommended for patients who cannot have surgery for other health reasons. Even if the tumor cannot be removed by surgery or destroyed entirely by radiation therapy, radiation therapy can still help relieve pain and make swallowing easier.
In radiation therapy for esophageal cancer, the energy usually comes from a machine outside the body (external radiation). Some patients also need treatment with radioactive materials placed in the tumor (implant radiation). Usually, patients receive external radiation therapy 5 days a week for several weeks. Most patients can stay at home and go to the hospital or clinic each day for this treatment. For implant radiation, patients must stay in the hospital for a short time. More information about radiation therapy can be found in the National Cancer Institute booklet Radiation Therapy and You.
Chemotherapy is the use of drugs to kill cancer cells. The doctor may suggest one drug or a combination of drugs. Chemotherapy may be used alone or combined with radiation therapy to shrink a tumor before surgery or to destroy cancer cells that remain in the body after surgery. Chemotherapy may also be used if surgery is not possible and for patients whose cancer returns after surgery or radiation therapy.
Most anticancer drugs for esophageal cancer are given by injection into a vein or muscle. Some may be taken by mouth. Chemotherapy is systemic therapy, meaning that the drugs travel through the bloodstream and can reach cancer cells all over the body. Often, the drugs are given in cycles: a treatment period followed by a rest period, then another treatment and rest period, and so on. Many patients have their chemotherapy as outpatients at the hospital, in the doctor's office, or at home. Depending on the drugs, the treatment plan, and the patient's general health, a hospital stay may be needed. The NCI booklet Chemotherapy and You has helpful information about this type of treatment.
TREATMENT STUDIES
Because esophageal cancer is so hard to control, many researchers are looking for more effective treatments. They are also exploring ways to reduce side effects. When laboratory research shows that a new method has promise, it is used to treated cancer patients in clinical trials. These trials are designed to answer scientific questions and to find out whether the new approach is both safe and effective. Patients who take part in clinical trials make an important contribution to medical science and may have the first chance to benefit from improved treatment methods.
Many clinical trials of new treatments for esophageal cancer are under way. Doctors are studying new ways of combining various types of treatment. They are also trying new anticancer drugs and drug combinations, as well as drugs that make cancer cells more sensitive to radiation. Another method under study is photodynamic therapy; the use of laser light and drugs that make the cancer cells sensitive to light so the laser can destroy them. Researchers are also exploring biological therapy ; treatment intended to help the body's immune system fight cancer more effectively.
Patients with esophageal cancer who are interested in taking part in a trial should talk with their doctor. They may want to read What Are Clinical Trials All About?, a booklet that explains the possible benefits and risks of treatment studies.
One way to learn about clinical trials is through PDQ, a computerized resource of cancer treatment information. Developed by the National Cancer Institute, PDQ contains an up-to-date list of trials all over the country. The Cancer Information Service, at 1-800-4-CANCER, can provide PDQ information to doctors, patients, and the public.
What are the side effects of treatment for cancer of the esophagus?
The methods used to treat cancer are very powerful. It is hard to limit the effects of therapy so that only cancer cells are removed or destroyed. Because healthy cells also may be damaged, treatment often causes unpleasant side effects.
The side effects of cancer treatment vary. They depend mainly on the type and extent of the treatment. Also, each person reacts differently. Attempts are made to plan the therapy to keep side effects to a minimum. Patients are carefully monitored so that any problems which occur can be addressed.
Surgery for cancer of the esophagus is a major operation. Patients who have had trouble eating and drinking may need intravenous (IV) feedings and fluids for several days before and after the operation. They may need antibiotics to prevent or treat infections. Patients are taught special coughing and breathing exercises to keep their lungs clear. Discomfort or pain after surgery can be controlled with medicine. Patients should feel free to discuss pain relief with the doctor.
Patients receiving radiation therapy may become tired as treatment continues. Resting as much as possible is important. It is also common for the skin in the treated area to become red or dry. The skin should be exposed to the air but protected from the sun, and the patients should avoid wearing clothes that rub the area. Good skin care is important at this time. The doctor may suggest certain kinds of soap, and patients should not use any lotion or cream on the skin without the doctor's advice. Radiation to the chest and neck can cause a dry, sore throat or a dry cough. Drinking extra liquids can be helpful, and doctors sometimes suggest cough medicine. If burning, tightness, or other pain makes it hard to swallow, the doctor may suggest a local anesthetic or soothing gargle for use before meals. Some patients find that antacids help relieve feelings of indigestion. A small number of patients feel short of breath during radiation therapy. The doctor may prescribe medicine to relieve this problem.
The side effects of chemotherapy depend on the drugs that are given. In general, anticancer drugs affect cells that divide rapidly. These include blood cells, which fight infection, cause the blood to clot, or carry oxygen to all parts of the body. When blood cells are affected by anticancer drugs, patients can have a lowered resistance to infection, bruise or bleed easily, and have less energy. Cells in hair follicles and cells that line the digestive tract also divide rapidly. Chemotherapy can therefore cause hair loss and other problems such as poor appetite, mouth sores, nausea, and vomiting. These side effects usually go away gradually after treatment stops.
The patient's weight is checked regularly because weight loss can be a serious problem for patients with cancer of the esophagus. Swallowing food can be difficult, and patients may not feel hungry if they are uncomfortable or tired. Yet, well- nourished patients generally feel better, have more energy, and are often better able to withstand the side effects of their treatment, so good nutrition is important. Patients with esophageal cancer are usually encouraged to have several small meals and snacks throughout the day, rather than to try to eat three large meals. It often helps to sit up for a while after eating, and the doctor may prescribe medicine to control nausea and vomiting and to relieve discomfort.
When swallowing is difficult, many patients can still manage soft, bland foods moistened with sauces or gravies. It can be helpful to prepare other foods in a blender. In addition, puddings, ice cream, and soups are nourishing and easy to swallow. Doctors, nurses, and dietitians may have other suggestions to help patients and their families choose foods that supply enough calories to control weight loss and enough protein to keep up strength and rebuild normal tissues. For example, they may suggest liquid dietary supplements or milkshakes made with extra protein powder or dry milk for patients who cannot swallow solid foods.
The health care team can explain the effects of esophageal cancer and its treatment, and they can suggest ways to deal with them. In addition, the NCI booklets Radiation Therapy and You, Chemotherapy and You, and Eating Hints provide helpful information about cancer treatment and coping with side effects.
How do patients with cancer of the esophagus and their families cope?
The diagnosis of esophageal cancer can change the lives of patients and the people who care about them. These changes can be hard to handle. It is common for patients and their families and friends to have many different and sometimes confusing emotions.
At times, patients and their loved ones may feel frightened, angry, or depressed. These are normal reactions when people face a serious health problem. Most people handle their problems better when they share their thoughts and feelings with those close to them. Sharing can help everyone feel more at ease and can open the way for people to show one another their concern and offer their support.
Worries about tests, treatments, hospital stays, and medical bills are common. Doctors, nurses, social workers, and other members of the health care team can help calm fears and ease confusion. They can also provide information and suggest resources.
Patients and their families are naturally concerned about what the future holds. Sometimes, they use statistics to try to figure out whether the patient will be cured or how long he or she will live. It is important to remember, however, that statistics are averages based on large numbers of patients. They can't be used to predict what will happen to a certain patient because no two cancer patients are alike. The doctor who takes care of the patient and knows his or her medical history is in the best position to discuss the person's outlook (prognosis). Patients should feel free to ask the doctor about their prognosis, but they should keep in mind that not even the doctor knows for sure what will happen.
Living with a serious disease isn't easy. Cancer patients and those who care about them face many problems and challenges. Finding the strength to cope with these difficulties is easier when people have helpful information and support services.
The doctor can explain the disease and give advice about treatment, working, or daily activities. If patients want to discuss concerns about the future, family relationships, and finances, it also may help to talk with a nurse, social worker, counselor, or a member of the clergy.
Friends and relatives who have had personal experiences with cancer can be very supportive. Also, it helps many patients to meet and talk with others who are facing problems like theirs. Cancer patients often get together in self-help and support groups, where they can share what they have learned about cancer and its treatment and about coping with the disease. It is important to keep in mind, however, that each cancer patient is different. Treatments and ways of dealing with cancer that work for one person may not be right for another,even if they both have the same kind of cancer. It is a good idea to discuss the advice of friends and family members with the doctor.
Often, a social worker at the hospital or clinic can suggest local and national groups that can help with emotional support, financial aid, transportation, or home care. The American Cancer Society is one such group. This nonprofit organization has many services for patients and their families. Local offices of the American Cancer Society are listed in the white pages of the telephone book.
Information about other programs and services is available through the Cancer Information Service. The toll-free number is 1-800-4- CANCER.
The public library is a good place to find books and articles on living with cancer. Cancer patients and their families and friends also can find helpful suggestions in the booklet Taking Time.
What resources are available to patients with cancer of the esophagus?
Information about cancer is available from many sources, including the ones listed below. You may wish to check for additional information at your local library or bookstore and from support groups in your community.
CANCER INFORMATION SERVICE (CIS) 1-800-4-CANCER
The Cancer Information Service, a program of the National Cancer Institute, is a nationwide telephone service for cancer patients, their families and friends, the public, and health care professionals. The staff can answer questions in English and Spanish and can send booklets about cancer. They also know about local resources and services. One toll-free number, 1-800-4- CANCER (1-800-422-6237), connects callers with the office that serves their area.
AMERICAN CANCER SOCIETY (ACS)
1599 Clifton Road, N.E.
Atlanta, GA 30329
1-800-ACS-2345
The American Cancer Society is a voluntary organization with a national office and local units all over the country. It supports research, conducts educational programs, and offers many services to patients and their families. To obtain free booklets about services and activities in local areas, call the Society's toll-free number, 1-800-ACS-2345 (1-800-227-2345), or the number listed under "American Cancer Society" in the white pages of the telephone book. - While the exact cause(s) of cancer of the esophagus is not known, risk factors have been identified.
- The risk of cancer of the esophagus is increased by long- term irritation of the esophagus, such as with smoking, heavy alcohol intake, and Barrett's esophagitis.
- Diagnosis of cancer of the esophagus can be made by barium x-ray of the esophagus, and confirmed by endoscopy with biopsy of the cancer tissue.
- Cancer of the esophagus can cause difficulty and pain with swallowing solid food.
- Treatment of cancer of the esophagus depends on the size, location, and the extent of cancer spread, as well as the age and health of the patient.
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