Esophageal Cancer

Overview

Esophageal cancers commonly arise from the inner lining of the esophagus, which is a muscular, hollow tube that connects the mouth to the stomach. Esophageal cancers can also affect the other layers of esophagus; however, it is more common in the inner lining.
 
Esophageal cancer is one of the top ten common cancers in India, and it is more prevalent in men than women. The main known risk factors for esophageal cancer include tobacco and alcohol consumption and betel quid chewing.

Types

Esophageal cancer, which is one of the gastrointestinal cancers, is categorised into various types based on its site of origin:
 

Symptoms

In most cases, difficulty swallowing is the initial symptom of esophageal cancer. Patients can feel the food being lodged in the throat and may also experience choking. In the beginning, this symptom is mild; however, it aggravates as the disease progresses and the patient might end up having difficulty in swallowing liquids too. Other key symptoms of esophageal cancers are:
 

• Vomiting
• Backache 
• Change of voice
• Cough
• Fatigue
• Unintentional weight loss 

Causes

There isn't enough information on what causes esophageal cancers. Nevertheless, researchers have discovered a number of risk factors that can lead to the development of esophageal cancer:

• Obesity: Being overweight or obese increases one’s risk of developing esophageal cancer.
• Gastro-esophageal Reflux Disease (GERD): Chronic GERD is associated with a higher risk of esophageal cancer development.
• History of Gastrectomy: Those who’ve had a gastrectomy in the past have an increased risk of esophageal cancer.
• HPV Infection: High-risk Human papillomavirus (HPV) infection is one of the risk factors for esophageal cancer.
• Tobacco and Alcohol Consumption: Esophageal cancer risk is high among those who consume tobacco and alcohol.
• Red Meat: Eating red meat or processed meat increases the risk of developing esophageal cancer.
• Zinc and Selenium Deficiencies: Low levels of zinc and selenium in the food may cause esophageal cancers
• Consumption of Areca Nut and Betel Quid: Studies have found that areca nut consumption increases esophageal cancers in younger populations. It is also found to lead to poor chemoradiation response and survival rates.

Diagnosis

There are various testing methods available for the detection and diagnosis of esophageal cancers:
 
a. Barium Swallow Test: During this test, the patient is made to swallow a liquid containing barium and undergo X-rays after some time. The barium films the insides of the esophagus, allowing the specialist to see any changes in the tissues upon an X-ray scan.

b. Esophagoscopy (Endoscopy): A flexible tube with a video lens (videoendoscope) is passed down the patient's throat and into the esophagus during endoscopy. This procedure helps in the examination of esophagus and looking for cancer or areas of inflammation.

c. Imaging Tests: Imaging tests, namely PET CT, ultrasound, etc., are recommended to understand the extent of the disease. These tests help in staging, treatment planning, therapy monitoring and restaging of the disease.

d. Biopsy: The sample for biopsy may be collected during the endoscopy. The tissue sample collected is later sent to a laboratory where it is examined for the presence of cancer cells.

Treatment

There are many treatment options available for esophageal cancers, irrespective of the stage. HCG has the best esophageal cancer specialists in India, who assess the patient information and devise treatment plans based on many crucial factors, such as the stage of the disease, exact location of the tumour, tumour grade, age of the patient, the overall condition of the patient and lastly, his/her preferences. 
 
The main treatment options available for esophageal cancers include surgery, radiation therapy, chemotherapy, immunotherapy, targeted therapy, laser surgery and other GI procedures.
 
a. Surgery: Esophageal cancer can be either operated via open surgeries or minimally-invasive surgeries. The surgical procedure will be chosen based on factors, such as the stage of the tumour, its location, age and overall condition of the patient. Surgery is the main line of treatment for esophageal cancers that have invaded the esophagus wall and are node-positive.
 
Esophageal cancers can also be treated with robotic surgeries, which come with multiple advantages for the patients, namely shorter hospital stays, reduced blood loss and pain, fewer treatment complications and faster recovery.
 
b. Radiation Therapy: Radiation therapy may be recommended for a few esophageal tumours. Radiation therapy may be administered before or after the surgery and may be combined with chemotherapy in order to enhance the overall efficacy of the treatment. Today, there are multiple advanced radiation therapy techniques (3D-CRT, IMRT, IGRT) available for the efficient management of esophageal cancers. Radiation therapy may be administered for the following purposes:

• To shrink the tumour
• To reduce the risk of relapse after the treatment
• To ease pain, swallowing difficulties and other discomforts in patients with advanced-stage esophageal cancers

c. Chemotherapy: Chemotherapy uses strong drugs to destroy cancer cells throughout the body. Just like radiation therapy, chemotherapy may be administered before or after the esophageal cancer surgery. Chemotherapy can be used to shrink the tumours before the surgery, destroy the residual cancer cells after the surgery and also alleviate pain in patients with advanced-stage disease.
 
d. Immunotherapy: Immunotherapy works by allowing the immune system to recognise and destroy cancer cells more effectively. Checkpoint inhibitors function by blocking certain protein receptors on the surface of cancer cells and/or immune cells and are commonly used in the treatment and management of esophageal cancers.
 
e. Targeted Therapy: Certain esophageal cancer patients may benefit from targeted therapy that targets specific proteins present on cancer cells and support their growth and multiplication. Targeted therapy may be recommended if surgery is not feasible or, in certain situations, to treat advanced esophageal malignancies that haven't responded to other treatment modalities.
 
f. Endoscopic Laser Therapy: Endoscopic laser surgery can be utilised to treat more advanced cancers that are causing an esophageal obstruction. Lasers can be utilised as a part of palliative therapy to punch a hole in the blockage and ease the swallowing difficulties for patients.
 
g. Photodynamic Therapy (PDT): PDT involves the use of photoactive agents (medications that are activated by non-thermal light) that are absorbed by cancer cells; these photoactive drugs eventually kill the cancer cells. This treatment may be used to ease the esophageal cancer symptoms, namely swallowing difficulties.
 
Other gastrointestinal procedures used in the management of esophageal cancers include balloon dilation, cryotherapy, 
stent placements, etc.

Frequently Asked Questions

1. Are esophageal cancers treatable?
 
Despite being one of the aggressive cancers, esophageal cancers can be treated and managed in many cases. Early-stage esophageal cancers can be treated with better clinical outcomes and higher survival rates. 
 
No symptom must be ignored and any symptom that persists for more than two weeks should be brought to the doctor’s attention as early as possible – this helps in early detection and timely treatment of the disease.
 
2. What is the link between Barrett's esophagus and esophageal cancer?
 
Barrett’s esophagus is a condition wherein the cells in the lining of the esophagus start changing. This condition is more prevalent among those with acid reflux (GERD); however, those without GERD can also develop Barrett’s esophagus. Individuals with this condition are found to be at a higher risk of developing esophageal adenocarcinoma. 
 
Although only a small percentage of individuals with Barrett’s esophagus develop esophageal cancers, it is important for them to monitor the condition in case they are diagnosed with it.
 
3. What are the possible side effects associated with esophageal cancer treatment?
 
The side effects may vary from patient to patient depending on the type of treatment administered. Potential side effects include fatigue, nausea and vomiting, diarrhoea, hair loss, pain while swallowing, problems related to digestion, headaches, bleeding, etc. 
 
A few people may need to eat smaller, more frequent meals after the treatment depending on the severity of their condition and treatment plan. They may also require occupational or speech therapy to retrain their swallowing skills.
 
4. What should I know about follow-up care after esophageal cancer treatment?
 
Regular medical checkups following treatment are necessary to ensure that any treatment complications are addressed on time. These follow-ups are also important to reduce the risk of a relapse. The interval between appointments will gradually lengthen if there are no signs of recurrence. However, the doctors will still continue to monitor patients for signs of recurrence regularly.
 
5. How can I prevent esophageal cancers?
 
Although you cannot prevent esophageal cancers completely, here are a few things that you can do to reduce your risk of developing this disease. 
 
Tobacco and alcohol consumption should be avoided. You must also keep your weight in check as obesity is one of the risk factors for esophageal cancers. GERD or acid reflux should not be ignored and must be treated properly as it is linked with Barrett’s esophagus and esophageal cancer formation. It is also important for you to cut down your red meat consumption and ensure that you have a balanced and nutritious diet to reduce your esophageal cancer risk.