What is the oesophagus?
The oesophagus (gullet) is the tube that carries food from your mouth to your stomach.
When food is consumed the muscles at the top of the oesophagus contract, forcing food and fluid downwards into the stomach. At the lower end of the oesophagus there is a muscular valve (the sphincter), which prevents food and fluid being pushed upwards from the stomach.
Around 20% to 30% of the population appear to have a weakness of the lower oesophageal sphincter (valve), which allows acidic stomach contents to splash back up into the oesophagus, causing heartburn and regurgitation (reflux), which is the subject of a separate Core leaflet (www.corecharity.org.uk/conditions/heartburn-and-reflux).
What is cancer (carcinoma) of the oesophagus?
The normal oesophagus is lined by squamous (skin like) cells. Cancer of the oesophagus develops from this lining and has the effect of narrowing the oesophagus and causing difficulty in swallowing. There are two main types of cancer of the oesophagus:
These develop directly from the squamous (skin like) cells which line the oesophagus. They account for most cancers occurring in the upper two thirds of the oesophagus.
These develop lower in the oesophagus, near to where it joins the stomach. The term adenocarcinoma is used because these cancers develop from glandular stomach like cells.
About 7500 people develop oesophageal cancer every year in the United Kingdom.
What causes cancer of the oesophagus?
What people eat has a big effect on the risk of developing a squamous cell carcinoma. High consumption of alcohol (particularly spirits), eating pickled or contaminated vegetables and drinking exceptionally hot liquid account for many worldwide differences. In the UK smoking and consumption of alcohol (particularly spirits) have a big effect in increasing risk.
This form of cancer is increasing rapidly, largely because of increased levels of obesity in the population at large. Obese patients are more likely to develop reflux (see separate leaflet). Some patients with reflux go on to develop a condition called Barrett’s oesophagus. In this condition the gullet reacts to the presence of acid by changing from squamous (skin like) to glandular (stomach like) cells. Unfortunately Barrett’s oesophagus is unstable and about 3% of patients with the condition go on to develop precancerous and then cancerous legions. Because of its rising incidence and overall importance for health, Barrett’s oesophagus and adenocarcinoma of the oesophagus are major areas of research application.
Cancers of the oesophagus are a bit more common in patients with coeliac disease and some rare genetic conditions and can be a complication of a condition known as achalasia, in which there is a failure of relaxation of the oesophageal sphincter.
What are the symptoms?
The symptoms of oesophageal cancer are similar, whether it is a squamous carcinoma or adenocarcinoma. The cancer obstructs the passage of food down the gullet so that it seems to get stuck after it is swallowed. At first this happens with solids such as meat and bread, then with softer foods and eventually there may be difficulty getting liquids down. Patients begin to lose weight and may have other symptoms, such as choking, coughing, unexplained chest infections or a hoarse voice. Unfortunately, oesophageal cancers have often spread before they come to light. Difficulties in swallowing should always be investigated promptly as there are many causes other than cancer.
Although reflux is important in the development of Barrett’s oesophagus and adenocarcinoma, these conditions often develop without any previous symptoms of reflux such as heartburn.
How is the diagnosis made?
Most patients seek medical attention because of difficult swallowing. Going to the GP early when symptoms begin is important, to increase the chances of early diagnosis and effective treatment. The GP is likely to make a referral to a specialist for investigations, most commonly by endoscopy, in which a narrow, flexible telescope is passed into the gullet through the mouth, using a local anaesthetic throat spray. Changes in the lining of the gullet can be seen and samples taken (biopsy) for laboratory examination.
Nowadays the endoscope often has an ultrasound scanner attached to it to scan the cancer from inside and see how deep it goes.
Sometimes a patient may have a barium swallow examination. This involves swallowing a white liquid containing barium, which shows up on x-ray, outlining the oesophagus and revealing any obstruction.
If cancer is diagnosed, other tests may be needed to see if it has spread. These include:
CT scan of the chest and abdomen - this is a whole body scan done to assess the size of the cancer and whether it has spread.
Staging laparoscopy - this is a keyhole examination, performed under a general anaesthetic, to see if the cancer has spread to areas that are not usually seen on a CT scan. This helps the doctor to decide if surgery is appropriate.
If surgery is considered, suitable heart and lung function tests are done to check on fitness for surgery.
Oesophageal cancers are difficult to treat, mainly because they have often spread by the time of diagnosis. Oesophageal cancer is managed by a team including specialist surgeons, endoscopists who can treat small cancers and oncologists who specialise in chemotherapy and radiotherapy treatment.
Often combination treatment is the most appropriate. Treatment varies according to staging the tumour using the results of the tests described above. In early stage tumours, treatment is directed at trying to cure the condition. In later stages the aim is symptom control.
Surgery is the appropriate treatment in about 20% of patients and about 35% of these can expect to live for more than 5 years and, in effect, be cured. Patients usually undergo chemotherapy and radiotherapy before surgery because recent research has shown this improves the outlook. This is an area of active research. For example one question is whether adding in radiotherapy to surgery and chemotherapy might improve the outlook further.
Depending on the position of the tumour, the surgeon may need to enter the chest cavity, the abdomen or the neck, and will remove the affected part of the oesophagus with the surrounding lymph glands. A tube is then made out of the stomach, which is drawn up into the chest or neck where it is joined to the remainder of the oesophagus.
Patients are usually cared for in an intensive care ward after this operation and after leaving hospital are able to eat normally, although may feel full rather quickly. This sensation usually improves over the following months.
Sometimes dysphagia (as mentioned earlier in the leaflet) returns weeks or months after the operation. This may be because the cancer has recurred, but often is due to scarring (a ‘stricture’) where the surgeon has made the join. These strictures can be easily stretched using an endoscope.
Curative endoscopic treatments
For a long time endoscopy has been used to manage symptoms in patients where the cancer cannot be cured (see below). Increasingly, it is used to treat early cancers or pre-cancerous lesions. The endoscopist dissects (cuts) around and underneath the cancer down to normal structures beneath and removes it. This avoids the need for surgery and can be done as an out- patient or with a brief hospital stay but is only suitable for the treatment of early cancers.
Radiotherapy and chemotherapy
As noted above, giving chemotherapy before surgery is a new approach that has improved the outlook. In some patients where surgery is unsuitable, high dose radiotherapy can be used for attempted cure (a radical radiotherapy). Sometimes lower dose radiotherapy and/or chemotherapy in lower doses are used in a palliative way to treat symptoms. Radiotherapy can be given as an external beam or from inside the gullet, using a radiation source (brachytherapy).
Treatment of symptoms
Endoscopic stenting plays a very important role in symptom control. A tube (stent) is inserted into the gullet, via an endoscope to keep it open, so that food and fluid can be swallowed without difficulty. Stenting is usually done under sedation in the endoscopy department. Stents are made of either plastic or springy metal coils. They can become blocked by large food particles. It is helpful to take fizzy water with meals to displace these particles. Specific instructions on diet are always provided. Sometimes stents lead to troublesome heartburn and regurgitation, which can be helped considerably by taking PPI acid suppressing medication.
Endoscopic laser treatment is also possible, and a specialist endoscopist will use a laser to destroy any tumour that is growing into the gullet. In some patients laser treatment and intubation need to be combined.
Newer treatments which are increasingly used include:
Endoscopic mucosal resection - this technique is used to remove pre- malignant lesions and small tumours at endoscopy.
Radio frequency ablation - essentially this involves microwaving the lining of the oesophagus so that it changes from Barrett’s back to squamous mucosa.
Photodynamic therapy (pdt) - this is an alternative to radiofrequency ablation. Patients are given a drug that sensitises cells so that light delivered down an endoscope can be used to destroy them.
Prevention of oesophageal cancer
Because oesophageal cancer is so challenging to treat once it has developed, there are major efforts in research and screening to identify patients at risk of oesophageal cancer before it develops.
Patients with Barrett’s Oesophagus usually undergo regular inspection of the oesophagus through an endoscope, to pick up pre-cancerous changes, known as dysplasia, and prevent progression to cancer. This is known as endoscopic surveillance. There are trials to define how often this should be done.
Current research is also investigating whether simple drug treatments such as aspirin given with an acid suppressing agent can prevent the development dysplasia or cancer.
Other research is evaluating how best to use the endoscopic treatments, including radiofrequency ablation and endoscopic removal of tumours as described above.
The earliest symptom of cancer of the oesophagus is likely to be difficulty in swallowing food, and prompt consultation with a GP and early investigation are important if a cure is to be achieved.
Curative treatment of cancer of the oesophagus usually involves chemotherapy followed by a surgical operation to remove the affected part of the oesophagus.
Unfortunately a cure is not always possible, but there are endoscopic treatments such as stenting as well as radiotherapy or chemotherapy which can relieve symptoms.
Research is in progress into ways of preventing cancer of the oesophagus, by picking up early pre-cancerous changes or by giving medications which prevent the development of cancer.
Need for research
The incidence of oesophageal cancer, particularly adenocarcinoma, is rising. Treatment is challenging but there have been recent advances. For all these reasons oesophageal cancer is a major focus of research activity. What current research is trying to do includes:
- A simple screening test for Barrett’s oesophagus that can be applied to the general population so that cancers can be anticipated before they develop.
- Better ways of detecting very early pre-cancerous lesions at endoscopy.
- Use of endoscopic treatment to avoid challenging surgery.
- Working out the best combination of chemotherapy, radiotherapy and surgery to increase the chances of a cure.
- Raising public awareness of the factors that increase the risk of oesophageal cancer and encouraging people to present at the first sign of any symptoms.
- A fundamental understanding of how Barrett’s oesophagus develops and progresses into oesophageal cancer.
- Which patients with Barrett’s oesophagus to monitor and how.
- Preventative treatments for patients with Barrett’s oesophagus to prevent development of oesophageal cancer.
Britain leads the way in research into Barrett’s oesophagus and oesophageal cancer. There is a great deal of research in this area but more needs to be done and funds are badly needed.
Fact sheet produced by Core and provided by MIMS
Last reviewed: July 2013
Core is the charity for research and information on gut and liver disease