Oesophageal cancer is usually one of two types. Adenocarcinoma usually occurs in the lower oesophagus at the junction with the stomach and is linked to Barrett’s oesophagus, even if this has not already been diagnosed. The second type is squamous cell carcinoma which tends to affect the upper part of the oesophagus and is more strongly linked to smoking and alcohol.

Early signs of oesophageal cancer

These can include:

• Worsening or persistent indigestion or heartburn
• Difficulty swallowing
• Weight loss without trying
• Chest pain, pressure or burning
• Coughing or hoarseness

How common is oesophageal cancer in the UK?

• The United Kingdom has the highest incidence of oesophageal adenocarcinoma in the world: 7.2 per 100,000 in men and 2.5 per 100,000 in women
• Between 2015-2017 there were around 9200 new cases of oesophageal cancer diagnosed each year, that’s 25 cases diagnosed every day
• Oesophageal cancer is the 14th most common cancer in the UK, accounting for 3% of all new cases
• It is the 9th most common cancer in males, with around 6,400 new cases diagnosed in 2017
• In females it is the 15th most common cancer, with around 2,800 new cases diagnosed in 2017

Cancer of the oesophagus is the 14th most common cancer in the UK and the 7th most common cause of cancer deaths

Prognosis

In England, 45% of all sufferers will survive for one year, but by 5 years only 15% will still be alive. This is because the majority of patients present with incurable disease. It has either spread too far from the oesophagus into local organs or secondary tumours (metastasis) have developed at other sites in the body (typically lymph glands, liver and lungs).

Prognosis is dependent on the stage of the cancer and whether or not it can be cured with the best current treatments. Less than 40% of patients can be offered curative treatment. These patients have a 74% chance of surviving for one year after diagnosis compared to 30% if the cancer is too advanced for curative therapy.

• There are around 7,900 oesophageal cancer deaths in the UK each year, that’s 22 deaths every day
• Oesophageal cancer is the 7th most common cause of cancer death in the UK, accounting for 5% of all cancer deaths in 2017
• In males in the UK, oesophageal cancer is the 4th most common cause of cancer death, with around 5,500 deaths in 2017
• In females in the UK, oesophageal cancer is the 7th most common cause of cancer death, with around 2,400 deaths in 2017

These statistics were compiled by Cancer Research UK.  Further detail is available on their website. 

Causes of oesophageal cancer

Squamous Cell Carcinoma

Oesophageal squamous cell carcinoma arises through chronic irritation and inflammation of the oesophageal lining. Risk factors vary between countries and cultures but in general it is a disease of poor nutrition, poor oral-hygiene and poverty. The strongest associations are smoking and alcohol but consumption of hot beverages, high intake of barbecued meat and human papilloma virus infection have all been implicated.

Adenocarcinoma

Adenocarcinoma is rare globally but more common in wealthy, industrialised western nations. It is most common in middle-aged, caucasian, obese, males with a history of excess alcohol consumption and smoking. Male-pattern obesity (fat carried around the waist and inside the abdomen) may be responsible for increased abdominal pressure and therefore acid reflux (often causing heartburn), going some way to explain why adenocarcinoma is seen far more commonly in men than women.

Adenocarcinoma of the oesophagus is strongly associated with gastro-oesophageal reflux disease (GORD) often described as heartburn.  GORD is a common disease whereas adenocarcinoma of the oesophagus is not.  GORD affects 1 in 10 adults on a daily basis and up to 2 in 10 weekly.  Of these a further 1 in 10 will have Barrett's oesophagus, the only known precursor for adenocarcinoma.  The risk of progression to cancer in this population is around 1 in every 1000 patients per year.

It is important to remember that the majority of patients with Barrett’s oesophagus will never develop oesophageal cancer.

How is oesophageal cancer diagnosed?

Anyone who exhibits one or more of the symptoms listed at the top of this page should see their doctor.  The first test performed is usually an endoscopy (a camera test to view the inside of the oesophagus and stomach) with biopsies (small samples of the lining are painlessly removed and examined under a microscope).

This image below shows an internal view of the oesophagus with an adenocarcinoma (highlighted yellow) in a field of Barretts oesophagus (highlighted red). 

 

The majority of patients are diagnosed with oesophageal cancer following a referral from their general practitioner (GP) or another hospital doctor (85%). A very small number (less than 1%) are identified because they are known to have Barrett’s oesophagus and undergo regular surveillance endoscopy. The remaining 14% present as an emergency.

Treatment of oesophageal cancer

Once staging has been completed a management plan will be developed and tailored to individual patients. This will take into account the stage of disease, other medical conditions and the wishes of the patient and their family.

Treatment of curable cancer

If oesophageal cancer is diagnosed early it can be cured. For the earliest stage cancers the tumour can be removed endoscopically (from the inside of the oesophagus in a similar way to the camera test used for diagnosis) without the need for major surgery or other treatments. If any Barrett’s oesophagus is present this will also be removed completely. More than one endoscopic treatment may be required.

Squamous cell cancer of the oesophagus often responds well to a combination of chemotherapy and radiotherapy.

Treatment of advanced and incurable cancer

In this situation treatment is aimed at improving the length and quality of life. Doctors may suggest a number of potential treatments or no treatment at all, depending on individual circumstances.

Surgery

Surgery remains the mainstay of curative treatment for oesophageal cancer. The aim of surgery is to remove the tumour, the oesophagus, the lymph nodes (that may contain cancer cells) and the surrounding tissue and to restore continuity of the digestive tract. By far the most commonly performed operation is an Ivor-Lewis oesophagectomy that involves operating in the abdomen and the chest. In the UK 96% of operations are performed in this way.  The procedure is demonstrated in the diagram to the right.

 

The role of keyhole (minimally invasive) and robotic surgery is expanding in oesophageal cancer. The perceived advantages are shorter recovery times, a reduction in complications and less post-operative pain.

The UK’s ROMIO clinical trial (Randomised controlled trial of minimally invasive or open oesophagectomy) coupled with similar trials in France (MIRO) and Holland (TIME), is designed to compare  the clinical and cost-effectiveness of minimally invasive and open surgical procedures in terms of recovery, health related quality of life, cost and survival. At present there is no convincing evidence that key hole surgery is better or worse than traditional open surgery and patients should be reassured that the type of operation that they receive will not determine their chances of survival or quality of life.

NICE Guidelines

Mimi McCord the founder of HCUK is a patient representative at NICE – the National Institute for Health and Care Excellence and has been involved in the preparation of the current guidelines covering the assessment and management of oesophago-gastric cancer in adults, including radical and palliative treatment and nutritional support.

59% of UK oesophageal cancer cases are preventable.  If you suffer with persistent heartburn see your GP.