Esophagus is a part of the digestive system that connects the throat to the stomach. It is a long, hollow, muscular tube, which lies behind the windpipe (trachea), and in front of the spine in the neck and in the thorax.
The swallowed food from the throat passes through the esophagus to the stomach, where the food will be digested.
Over the past few decades, esophageal cancer has become more prevalent and is responsible for increased cancer deaths. Hence, it is important to learn more about esophageal cancer, its signs and symptoms, how it can be diagnosed and its treatment methods.
What is Esophageal Cancer?
Esophageal cancer is a type of cancer that occurs anywhere along the esophagus. Cancer occurs when the cells begin to divide and grow abnormally, in an uncontrolled manner.
These cells have the ability to grow into the surrounding tissues and spread to other organs and areas of the body.
Esophageal cancer usually starts in the inner lining of the esophagus and grows outwards into the outer layers.
Are there different types of Esophageal Cancer?
The esophagus is made up of several layers of tissues, which have different types of cells. Depending on the cells involved, esophageal cancer is mainly classified into two types:
Squamous cell carcinoma (SCC)
The innermost layer of the esophagus, known as mucosa, is lined with squamous cells, which are thin, flat cells. The cancer that begins in these cells is called squamous cell carcinoma.
It most commonly occurs in the cervical or upper 1/3rd part of the esophagus & middle 1/3rd of the esophagus. This is the most prevalent type of esophageal cancer, accounting for about 90% cases worldwide.
The esophagus has cells that secrete the mucus, which covers the inner lining, known as glandular cells. Cancer that develops in these cells is called adenocarcinoma.
It most often begins in the lower portion of the esophagus. In conditions like Barrett’s esophagus, the glandular cells replace the squamous cells of the esophagus, which might lead to adenocarcinoma. Although the prevalence of SCC is high, the death rates due to AC are higher than SCC in some regions of the world.
About 95% of esophageal cancers are SCC and AC. The other rare types of esophageal cancer include sarcoma, small cell carcinoma, melanoma, lymphoma, and choriocarcinoma. Knowing the type of esophageal cancer, helps determine the treatment options.
How common is Esophageal Cancer in India?
According to the latest statistics, esophageal cancer is the 5th most common cancer in India. About 63,180 new cases were registered in the year 2020.
The statistics also suggest that the incidence rate of this cancer was high in men (6.1%) than women (3.4%).
How can I know if I have Esophageal Cancer?
Esophageal cancer usually does not present any symptoms in its early stages. Hence, it is often diagnosed during its advanced stages.
However, some of the following symptoms may indicate esophageal cancer:
- having problems swallowing (dysphagia)
- unexplained weight loss
- loss of appetite
- pain in the throat or middle of the chest, particularly when swallowing
- worsening indigestion or heartburn
If you have any of these signs and symptoms, consult a doctor for further clinical evaluation.
How is this disease diagnosed?
During the consultation, your doctor would ask about the symptoms and medical history, and examine you closely. A blood test may be recommended to check your general health.
If there are signs of esophageal cancer, further tests may be done, which may include:
Barium swallow study
In this test, you are asked to swallow a barium-containing liquid which is radiopaque. The barium coats the inner lining of your esophagus and shows changes in the tissues on an X-ray. This helps the doctor assess if there are any growths or obstructions in the esophagus.
A flexible tube with a camera at one end, called endoscope is passed down your throat. This test facilitates to look for esophageal cancer or areas of irritation.
For this test, a special endoscope will be passed down the throat to collect a small sample of suspicious tissue, which is analysed in the laboratory.
This test provides crucial information about whether the cells in the esophagus are normal or cancerous, and in which stage.
Other imaging tests like computed tomography (CT) scan, magnetic resonance imaging (MRI) scan, positron emission tomography (PET) scan may also be performed to diagnose esophageal cancer.
The staging of the esophageal cancer involves further tests to determine whether the cancer has spread to the lymph nodes or other parts of the body. This may include the following tests:
A bronchoscope, which is a thin, lighted tube, is inserted into the nose or mouth to examine the trachea and airways. This test helps to detect cancer in the trachea or the airways.
In this test, like in endoscopy, an endoscope is passed through the throat. It uses sound waves bounced off of organs in the body to create images of internal structures. This test provides more details on the size and extent of the tumour.
In this test, a series of narrow beams pass through the body to create 2-dimensional cross sectional images of the body. This provides a more detailed picture than an X-ray image.
A safe injectable radioactive chemical is injected into the body, which is absorbed majorly by the tumour cells and is detected by the PET scanner. The scanner produces the images of the organs and tissues.
You can read here about how to prepare for a PET scan.
An incision is made in the chest through which an endoscope is inserted to view the lymph nodes and other chest organs. During this test, biopsies can also be performed.
An incision is made in the abdomen, through which a lighted tube is inserted to examine the organs and obtain tissue samples to evaluate for cancer spread.
Based on the size of the cancer and extent of spread, esophageal cancers are classified into five basic stages, which are indicated by Roman numerals 0 to IV.
Stage 0 indicates that the cancer is small in size and has affected only the superficial layers of the esophagus, whereas stage IV is where the cancer has spread to distant part of the body.
Owing to advancements in cancer diagnosis and treatment, the cancer staging system continues to evolve into a more complex system. Knowing the stage of the cancer exactly gives more information about your case, which helps in planning your cancer treatment.
How is Esophageal cancer treated?
Esophageal cancer treatment requires a multidisciplinary approach; in the majority of the patients, it involves medical, surgical and radiation oncology. The type of treatment received depends on the type of the esophageal cancer, its stage, its location, your overall health and your preference.
Your doctors will explain the different treatment approaches, their risks and side effects, and help you make treatment decisions. A team of doctors will discuss the treatment with the best possible outcome for your case.
The following are some of the treatment approaches discussed in brief.
The type of surgery performed to treat esophageal cancer depends on the size and precise location of the cancer, and the technique used by your surgical oncologist.
Surgery for esophageal cancer usually involves removing the esophagus, which can be done by different techniques:
During this procedure, a part of the esophagus that contains cancer and often a smaller portion of the stomach is removed. The remaining portion of the esophagus is connected to the stomach.
Sometimes, the entire esophagus is removed, this is called total esophagectomy. This procedure can be performed as an open procedure with large incisions, or through several small incisions using special surgical tools (laparoscopically/Robotic). The esophagus is then replaced with a tubularised stomach or jejunum (a part of small intestine) or colon (a part of large intestine) to restore continuity and facilitate oral feeds.
The main risks of esophagectomy include bleeding, blood clots, infection, pneumonia, hoarse voice, swallowing problems, lymphatic leakage or leaking at the region where the esophagus and stomach are connected.
A part of the esophagus, along with the upper portion of the stomach and nearby lymph nodes are removed, and the remaining part of the stomach is pulled up and reattached to the esophagus.
Esophagogastrectomy may lead to pulmonary complications such as pleural effusion and pneumonia, cardiac complications such as myocardial infarction and cardiac arrhythmias, as well as risk of infection, leakage from the new connection between the stomach and esophagus
In chemotherapy, anticancer drugs are given and these circulate throughout the body in the bloodstream and kill the cancer cells.
The drugs administered will depend on the cancer type and stage. Chemotherapy can be given before or after surgery, or even combined with radiotherapy.
In cases of advanced esophageal cancers, chemotherapy may be used to relieve the symptoms & increase the survival.
For advanced cases of esophageal cancers, immunotherapy and targeted therapy options are also available. Immunotherapy options include targeted antibodies, such as ramucirumab, trastuzumab, and immunomodulators, nivolumab and pembrolizumab.
The side effects of chemotherapy depend on the types of drugs received. Some of the side effects include nausea, vomiting, hair loss, mouth sores, loss of appetite, diarrhea or constipation.
You can read here about the best diet to follow during chemotherapy.
Radiation therapy involves high-energy beams, like protons or X-rays, which are usually emitted from an external machine (external beam radiation), target the cancer cells and kill them.
This type of radiation therapy is commonly used for the treatment of esophageal cancer. Sometimes, radiation can be placed near the cancer inside the body, this is known as brachytherapy.
Radiation therapy can be combined with chemotherapy, or given before or after surgery. It can also be used in advanced cancers to relieve the symptoms, where the cancer grows large enough to block food intake in the esophagus or if there is bleeding from the tumour.
Radiation therapy can also cause certain side effects during or after completion of radiotherapy, which include painful or difficulty in swallowing, skin reactions and damage to nearby organs.
You can read about the side-effects of radiation therapy here.
How can I ensure good nutrition during esophageal cancer treatment?
Esophageal cancer makes swallowing food difficult and painful, therefore affecting the nutrition received.
Most of the patients experience weight loss and malnutrition leading to treatment discontinuation.
Getting enough nutrition is essential before, during and after cancer treatment to maintain your physical strength and a healthy weight, fight infection, cope with the side effects, and speed up your recovery.
Here are some tips that can help:
- Have foods high in calories and protein, like eggs, cheese, yogurt, peanut butter, etc.
- Soften your food with sauces or gravies, or chop food into small pieces if swallowing is difficult.
- Have smaller meals at frequent intervals.
- Drink fluids when eating food to make swallowing easier.
Consult a professional nutritionist for further guidance. Your nutritionist will help you achieve good nutrition and help with recovery.
In case you are unable to receive enough nutrition from eating or drinking on your own, a feeding tube may be inserted. There are different types of feeding tubes.
Jejunostomy tube (J tube)
It is a soft, plastic tube inserted through the skin and attached to the middle part of the small intestine.
Nasogastric tube (NG tube)
This tube is inserted into the nose, through the esophagus and in the stomach. This can be done under endoscopy guidance also.
Percutaneous endoscopic gastrostomy (PEG tube)
This tube is passed through the skin and muscle of the abdomen, directly into the stomach.
If you are using a feeding tube, you will be put on a strict diet, which will help your esophagus and stomach heal. This diet begins with a clear liquid diet, moves to full liquid diet and slowly transitions into a soft diet.
When the esophagus and the stomach heals, the feeding tube will be removed and you will slowly start drinking and eating normally.
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