Oesophageal Cancer

The oesophagus (sometimes known as the food pipe or gullet) is the organ in the digestive system that connects your mouth to your stomach.  

It is a hollow tube of muscle that is about 25cms long in adults. The inside of the oesophagus is normally lined by flat “paving slab” like cells (called a stratified squamous epithelium). These cells sit on a membrane that separates the lining from the layers of muscle. 

Cancer can develop at any point along its length. And because the oesophagus doesn’t have an outer layer like many other organs, sometimes cancer cells can get into it or through it to other nearby organs. 

Oesophageal cancer is usually one of two types: 

1. Adenocarcinoma is the most common type in the UK and usually occurs in the lower part of the oesophagus at the point where it meets the stomach and can be linked to Barrett’s oesophagus. Adenocarcinoma develops in the lining of cells that have changed shape and size due to long-term exposure to stomach and bile acids through gastro-oesophageal reflux. They then go from looking like “paving slabs” under the microscope, to looking more like piled up columns.
2. The second, and the most common type worldwide, is squamous cell carcinoma (SCC) which tends to affect the upper part of the oesophagus and is more strongly linked to smoking and drinking alcohol.

The most common symptoms of cancer of the oesophagus include but are not limited to:

• Worsening or persistent indigestion or heartburn.
• Difficulty swallowing (dysphagia) or food sticking.
• Weight loss without trying.
• Chest pain, pressure or burning.
• Feeling or being sick.
• Coughing or hoarse voice.

Other reported symptoms include:

• Regurgitation (food coming back into your mouth)
• Acid taste in mouth.
• Hiccups

If you experience any of the above symptoms for three weeks or more, you should make an appointment to see your doctor. 

Having these symptoms does not necessarily mean you have cancer of the oesophagus. There are many, much less serious, conditions that could be the cause but if you have persistent symptoms, it’s better to get checked.  If the GP feels further investigations are needed, you will be referred to a specialist.

Here are the known risks linked with the two types of oesophageal cancer.

Adenocarcinoma

• Adenocarcinoma is rare globally but is more common in richer countries including the UK. 
• Anybody can get oesophageal cancer, although it is more common in middle-aged, white men from a European background (Caucasian) who drink alcohol, smoke, and carry too much weight, especially around their waist and belly area.
• Extra fat around the waist and inside of the abdomen may cause pressure on the stomach and cause acid reflux (and heartburn). As this is more usual for men than women, researchers believe this could be part of the reason why more men than women develop this kind of cancer.
• Adenocarcinoma of the oesophagus (the food pipe) is strongly associated with GORD, which stands for gastro-oesophageal reflux disease, which is often described as heartburn. It is important to note that GORD is a common disease, but adenocarcinoma of the oesophagus is not.
• GORD affects 1 in 10 adults each day.  Of these people, about 1 in 10 will have Barrett's oesophagus, the only known condition that can sometimes turn into adenocarcinoma (this is sometimes called a precursor for adenocarcinoma).  For every 1000 people who have Barrett’s oesophagus about one person is likely to develop cancer each year. So, although it is important for it to be watched and checked, it only rarely turns into cancer. 

Squamous Cell Carcinoma (SCC)

• Oesophageal squamous cell carcinoma is often linked to the lining of the oesophagus being seriously irritated or inflamed.
• The cancer normally grows in the middle or the top of the oesophagus.
• It’s linked to smoking and drinking too much alcohol. Drinking very hot drinks, eating a lot of barbecued food, and being infected by HPV (the human Papilloma Virus) can also be a risk factor.

If you experience any of the symptoms, we’ve listed above, for three weeks or more, you should make an appointment to see your doctor. 

If the GP feels further investigations are needed, you will be referred to a specialist who may send you for one or more of the following tests:

• Usually, the first test to be done is an endoscopy, also known as a gastroscopy. This is a camera test to view the inside of the oesophagus and stomach to see if anything obvious or worrying is going on. While they are having a look around, they may also take biopsies, which are small samples of the lining of the stomach or food tube. You won’t even feel them being taken. They will then be sent away to a lab to be looked at under a microscope.  
• Before the endoscopy, you could be asked to do a barium swallow, which means drinking a white liquid containing barium, which will then show on an x-ray.  This allows medical professionals to look at the oesophagus and see anything that is causing any blockages.
• Another test that’s sometimes done is called a trans nasal endoscopy (TNE), It’s like an endoscopy but instead of the camera going down your throat it goes up through your nose.  Biopsies can also be taken.  
• A new diagnostic test is also being trialled within the NHS, called The Capsule Sponge test.  It is less invasive than using cameras. If you’re offered this test, with the help of a nurse, you’ll be asked to swallow a pill on a string, which is about the size of a large, vitamin tablet.  The capsule sits in your stomach for about seven minutes as the coating dissolves to reveal a small sponge.  When it’s time, the nurse will then gently, but quickly, pull on the string to allow the sponge to travel up your oesophagus, picking up cells from the lining on the way. The sponge will then be sent to a lab for testing. If this picks up any abnormal cells, you’ll be asked to come for more tests typically an gastroscopy.

If cancer is found

If cancer is found, you’ll be sent for follow-up tests to find out things such as exactly what kind of cancer it is and if it is still only in the oesophagus, or if it has spread to other parts of the body.

Normal tests include an x-ray and ultrasounds of the chest area and CT and/or PET scans.  The results of these and any previous tests and biopsies will help stage the cancer and enable the doctors to work out the best treatment options for you.  A multidisciplinary team (MDT), made up of experts from lots of different medical areas, will help decide this. The MDT might include specialist cancer doctors (oncologists), cancer surgeons, endoscopy doctors and x-ray doctors as well as cancer nurses, dietitians, and any other relevant experts.

Oesophageal cancer is often treatable. But like most cancers, the earlier it is caught, the better the outcome usually is. One or more of the following treatments may be used:

Endoscopic mucosal resection (EMR) is where a doctor will remove abnormal cells from the inside of the oesophagus in a similar way to the camera test used to look for the cancer.  This may need to be done more than once.

Endoscopic submucosal dissection (ESD) is a procedure used to remove early-stage cancer in the lining of the oesophagus (food pipe). It is similar to EMR but it removes the abnormal area in one segment.

Radiotherapy is a treatment using a high-energy beam of X-rays targeted to a precise area.  It can be a stand-alone treatment or can be offered with other treatments, such as chemotherapy.

Chemotherapy could be offered before or after surgery or as a stand-alone treatment. This is a treatment where strong medicine is used to kill cancer cells.  There are many types of chemotherapy, but they all work in a similar way.  They stop cancer cells reproducing, which prevents them from growing and spreading in the body.

Immunotherapy uses the body’s own immune system to find and attack cancer cells. This treatment is not commonly available to people with cancer of the oesophagus on the NHS but can sometimes be offered as part of a clinical trial.

Surgery is often needed for the oesophageal cancer to be removed completely. The aim of surgery is to remove the tumour, the oesophagus, the lymph nodes (that may contain cancer cells) and the surrounding tissue. It will try to make it so that people can eat and drink in the normal way.

The Ivor-Lewis oesophagectomy is, the most performed type of surgery for cancer of the oesophagus. It involves operating in the abdomen and the chest. When the oesophagus or part of the oesophagus is removed, a tube is made from the stomach instead, which is then drawn up into the chest or neck to where it is joined to the remainder of the oesophagus. Patients are usually cared for in an intensive care ward after this operation. In the UK, 87% of operations are performed in this way.  Have a look at the diagram below to see how this operation is done.

The surgeon may do the operation via keyhole (using instruments fed through a small hole in your skin or - if it’s needed - by making a larger open skin incision).  It depends on the location of the cancer and other factors, such as the spread to the nearby lymph nodes.  Robotic surgery is also being performed for this type of cancer in a similar fashion to keyhole surgery.  

If the cancer is too advanced for treatment that may cure it, the aim will be to improve the length and quality of life for the patient. Doctors may suggest a mix of treatments or no treatment at all, depending on individual circumstances.

If swallowing becomes difficult but surgery is not possible, there are other ways to help. 

Endoscopic stent placement is carried out under a general anaesthetic or with sedation by a doctor or specialist in an endoscopy department.  A stent (a small tube) is put into the food pipe (the oesophagus) to keep it open and help people swallow food and liquid more easily.  The stent is made of plastic or springy metal coil. People who have a stent normally need to follow a strict diet to stop the stent getting blocked by large bits of food. Drinking fizzy drinks after eating can help keep the tube clean and clear.

Endoscopic laser treatment may also be performed by a specialist endoscopist who will use a laser to destroy any tumours growing in your oesophagus.

There are many people and organisations available to help you through your cancer journey and HCUK are one of them.  HCUK has an online support group on Facebook and there are support groups who meet in Basingstoke, Cambridge, and London.

Generally, during treatment, you will be assigned a Specialist Nurse who will be on hand to support you following your diagnosis.  They will often be the first person to turn to if you have any questions.

If your cancer is treatable but not curable you will be offered support from palliative care doctors and other health care professionals who specialise in helping you cope with your situation.

Don’t be put off by the words ‘palliative care’ which are often confused with ‘end of life’ care.  For some people living with cancer, palliative care - pain and symptom relief - can help make life easier and more comfortable.