Esophagus Cancer

What Is Cancer of the Esophagus?

The esophagus is a muscular tube that connects the mouth to the stomach. It carries food and liquids to the stomach. It is about 10-13 inches long. At its smallest point, it is a little less than
one inch wide.

The wall of the esophagus has several layers. Cancer of the esophagus starts from the inner layer and grows outward.

At the top of the esophagus is a special muscle that relaxes to let food or liquid enter. This muscle is called a sphincter. The lower part of the esophagus connects to the stomach. Another muscle here opens to allow food to enter the stomach. This muscle also keeps stomach acid and juices out of the esophagus. When stomach juices escape into the esophagus, we feel heartburn. The medical term for heartburn is reflux.

Long-term reflux of stomach acid into the esophagus sets up a special problem. It can change the cells in the lower end of the esophagus. They become more like the cells that line the stomach. These changed cells produce a condition called Barrett esophagus. The altered cells can change into cancer, so they should be closely watched by a doctor.

There are 2 main types of cancer of the esophagus. One type grows in the cells that form the top layer of the lining of the esophagus. These are called squamous cells, and cancer that starts there is known as squamous cell carcinoma. Squamous cell cancer can grow anywhere along the length of the esophagus. It accounts for about half of all cancers of the esophagus.

The other type usually starts near the opening to the stomach. It is called adenocarcinoma. This type of cancer cannot start unless squamous cells have been changed by acid reflux.

What Causes Cancer of the Esophagus?

While we don't know the exact cause of esophageal cancer, we do know some of the risk factors that make this cancer more likely. A risk factor is something that increases a person's chance of getting cancer. Some risk factors, such as smoking, can be controlled. Others, like a person's age or race, can't be changed.

Risk Factors for Cancer of the Esophagus

Age: The risk of this cancer goes up with age. It is rarely found in people under 40.

Sex: Men are 3 times more likely to get this cancer than women.

Race: African Americans are 50% more likely to develop cancer of the esophagus than whites.

Barrett esophagus: This occurs because of long-term reflux of fluid from the stomach into the lower esophagus. Some people feel heartburn from this reflux and others do not. Over time this reflux can change the cells at the end of the esophagus. This raises the risk of adenocarcinoma of the esophagus. But not everyone with Barrett esophagus will get cancer of the esophagus.

Heartburn: Long-standing heartburn, also called reflux (or GERD: gastroesophageal reflux disease), increases the risk of this cancer even if it hasn�t progressed to Barrett esophagus.

Tobacco: Using any form of tobacco raises the risk of this cancer. The longer a person uses tobacco, the greater the risk. More than half of all squamous cell esophageal cancer is linked to smoking.

Alcohol: Long-term heavy drinking is a major risk factor for cancer of the esophagus. For people who both smoke and drink, the risk is further increased.

Overweight: The risk of this cancer is higher for people who are overweight or obese.

Diet: Diets that don�t include enough fruits or vegetables and certain minerals and vitamins can raise the risk of this cancer. Overeating, which leads to being overweight, also raises the risk of this cancer.

Very hot liquids: Drinking lots of very hot liquids might increase the risk of this cancer.

Chemicals: Working with a chemical used in dry cleaning may lead to a greater risk of this cancer. Dry cleaning workers have a higher rate of cancer of the esophagus. Also, breathing in many other chemical fumes may also increase the risk.

Lye: Lye is found in strong cleaners like drain cleaners. It can burn and destroy cells. If a child accidentally drinks one of these cleaning liquids, the lining of the esophagus will scar. A child who has swallowed lye has a higher risk of squamous cell cancer as an adult.

Achalasia: In this disease, the muscle at the bottom of the esophagus does not open to release food into the stomach. So the lower end of the esophagus expands. Food collects there instead of moving into the stomach. This raises the risk for squamous cell cancer.

Tylosis: This is a rare, inherited disease. Extra skin grows on the palms of the hands and soles of the feet. People with tylosis are at a very high risk for esophageal cancer. They should be seen by a doctor regularly.

Esophageal webs: These are abnormal pieces of tissue that extend into the esophagus. They can make it hard to swallow. People who have these usually have other symptoms as well. They can have problems with the tongue, fingernails, spleen, and other organs. About 1 in 10 people with this problem will get cancer of the esophagus.

How Is Cancer of the Esophagus Found?

People with Barrett esophagus and others at high risk should have exams to look for cancer of the esophagus. The doctor might recommend surgery (or other methods) if certain abnormal cells (dysplasia) are found.

In most cases, this type of cancer is found because of the symptoms it causes. But often these symptoms don't appear until the cancer is advanced, making a cure less likely. If the cancer is found early, it is often a result of tests done for other reasons.

Below are the most common symptoms of this type of cancer:

Trouble with swallowing (dysphagia: dis-FAY-jee-uh): This is the most common symptom of cancer of the esophagus. It means that you feel as if food is lodged in the chest. By this time, if cancer is present it has grown to fill about half the opening of the esophagus. Solid foods like bread and meat often get stuck. People with dysphagia often switch to softer foods or even liquids to help with swallowing. To help the food go down, the body makes more saliva. This causes some people to bring up lots of thick mucus or saliva.

Pain: Rarely, pain in the mid-chest, or a feeling of pressure or burning, can be a sign of cancer. But these symptoms can also be caused by something else, such as heartburn. Pain while swallowing is usually a late sign of a large cancer.

Weight loss: About half of people with esophageal cancer lose weight without trying. This is because they are not getting enough food since they have trouble swallowing. Also, they may find they have less appetite.

Other symptoms: Hoarseness, hiccups, pneumonia, and high calcium levels are usually signs of more advanced cancer. Of course, these symptoms can be caused by other diseases as well.

How Is Cancer of the Esophagus Treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

After the cancer is found and staged, your doctor will talk to you about a treatment plan. There is a lot for you to think about when choosing the best way to treat or manage your cancer. There may be more than one treatment to choose from. You may feel that you need to make a decision quickly. But give yourself time to absorb the information you have learned. Talk to your doctor. Look at the list of questions at the end of this piece to get some ideas. Then add your own.

You may want to get a second opinion. A second opinion can provide more information and help you feel good about the treatment you choose. Some insurance companies require you to get a second opinion before they will agree to pay for treatments.

Surgery, chemotherapy, and radiation are used to treat early cancer of the esophagus. There are also treatments to help relieve pain and help with symptoms.

The best choice for you will depend on the stage of the cancer as well as your general health. Each kind of treatment might have side effects. Your cancer care team will be glad to discuss the side effects with you.

Surgery

How much surgery is done depends on the stage of the cancer. Surgery can also be used along with other treatments such as chemotherapy and radiation treatment.

There are 2 common types of operations for this cancer. In one, esophagectomy (ee-sof-uh-JEK-tuh-me), the part of the esophagus with cancer and nearby lymph nodes are removed. The esophagus is attached either to the stomach or the surgeon may replace the removed part of the esophagus with a piece of the small or large intestine.

The other surgery, esophagogastrectomy (ee-sof-uh-go-gas-TREK-tuh-me), is done to remove part of the lower esophagus, nearby lymph nodes, and the upper part of the stomach. The esophagus is again connected to the remaining part of the stomach.

While surgery can cure some patients whose cancer has not spread beyond the esophagus, often these cancers are not found early enough. So it�s important to know the goal of surgery: is it to try to cure the cancer or to ease symptoms?

Both of these operations are complex. Some surgeons are able to do the operation using a laparoscopic approach. This means that small cuts are made through which the doctor uses a tiny instrument something like a telescope to look inside the body. The surgery itself is done through even smaller incisions.

Surgeons who do this surgery must be quite expert. You should feel free to ask your surgeon about his or her experience with these operations and what percent were successful. The success rate is greater when the surgery is done in a hospital where it is done more often.

Most people stay in the hospital for 2 weeks after surgery. And there can be risks and side effects. For example, after the operation the stomach may empty very slowly, causing nausea and vomiting. The place where the esophagus connects to the stomach can become more narrow, making it hard for the person to swallow. Also, acid from the stomach can enter the esophagus causing heartburn. Anyone who has problems with side effects should talk with their doctor or nurse as there are often ways to help.

Some complications from surgery can be very serious, even fatal. It is important to have a surgeon with experience in a hospital where these operations are done more often. Don�t be afraid to ask the surgeon about his or her experience and about the survival rates at the hospital.

Radiation Therapy

Radiation therapy is treatment with high energy rays (such as x-rays) to kill or shrink cancer cells. External radiation uses a beam from outside the body. This is the kind most often used for cancer of the esophagus. For internal or implant radiation, radioactive �seeds� are placed directly inside the body near the cancer.

Radiation therapy by itself will not cure esophageal cancer. Often it is combined with surgery and/or chemotherapy. It is also used to relieve problems with swallowing, pain, or other symptoms of this cancer.

Side effects of radiation treatment may include skin problems, upset stomach, diarrhea, and fatigue. Often these side effects go away when treatment ends. Radiation to the chest may cause lung damage and lead to trouble breathing and shortness of breath. If you have these or other side effects, talk with your doctor since there are often ways to relieve them.

Chemotherapy

Chemotherapy refers to the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they spread throughout the body.

Chemotherapy alone cannot cure cancer of the esophagus unless radiation treatment (and in some cases surgery) are also used. Chemotherapy is used in 3 ways:

• It can be used to ease the symptoms of advanced cancer.
• It can be given along with radiation to shrink the cancer.
• It can be used before surgery to shrink a tumor. This use is still being studied.

Chemotherapy can have some side effects. These side effects will depend on the type of drugs given, the amount taken, and how long treatment lasts. The most common side effects can include:

• nausea and vomiting
• loss of appetite
• hair loss
• mouth sores
• increased chance of infection (from a shortage of white blood cells)
• bleeding or bruising after minor cuts or injuries (from a shortage of blood platelets)
• tiredness or shortness of breath (from a shortage of red blood cells)

Most side effects go away once treatment is over. Anyone who has problems with side effects should talk with their doctor or nurse as there are often ways to help.

PDT (photodynamic therapy): This method may be used when the cancer has been found very early or has come back after other treatment. First, a harmless chemical is injected into the bloodstream. It collects in the tumor for a few days. Then a special type of laser light is focused on the cancer through an endoscope. The light changes the chemical into a new chemical that can kill cancer cells.

PDT is useful because it can kill cancer cells with very little harm to normal cells. But because the light must be used, it can reach only cancers near the surface of the esophagus. It doesn�t work for cancers that have spread deeper or into other organs.

Side effects of PDT include redness or discoloration of the skin and sensitivity to the sun or other light sources. Because of this, people having this treatment may be told to stay indoors for 6 weeks.

At this time, the main use of PDT is to relieve symptoms of advanced cancer that are blocking the esophagus. It is also being used to treat Barrett esophagus and very early cancers found in Barrett esophagus. Researchers are looking at the use of PDT in comparison to other treatments such as surgery or the use of lasers.

Survival Rates by Stage (from the National Cancer Data Base; based on 11,154 patients diagnosed in 1998)

Because this cancer is usually found at an advanced stage, many people will die of the disease. But survival rates have been getting better. Talk with your cancer care team if you have questions about your own chances of a cure, or how long you might survive your cancer. They know your situation best.

The 5-year survival rate is the percentage of patients who are alive 5 years after diagnosis (leaving out those who die of other causes). Of course, patients might live more than 5 years after diagnosis.

Stage	5-year relative survival rate
0	52%
I	41%
II	26%
III	13%
IV	3%