What is esophageal cancer?

Esophageal cancer is a cancer that affects the esophagus- a long, hollow, and muscular tube that runs from the throat to the stomach.  It is responsible to move food and liquids towards the stomach.  It is located just behind the trachea (windpipe) and measures around 25 cm in adults.

In the United States, esophageal cancer is the 7^th most common cause of cancer death in males.  According to the American Cancer Society, around 18,500 new cases of esophageal cancer will be diagnosed in the year 2020.  Worldwide, esophageal cancer is the 9^th most common cancer and is 4 times more common in men than women.  In addition, it most commonly affects people aged between 60 and 70 years.

What are the risk factors for esophageal cancer?

Esophageal cancer occurs when there are mutation in the esophageal cells which result in uncontrolled proliferation of these cells.  These abnormal cells eventually form a mass or tumour leading to obstruction of the esophagus.  Furthermore, these cells may even spread to nearby structures and other parts of the body.  There are certain factors which may increase your risk of developing esophageal cancer and these include:

• Suffering from gastro-esophageal reflux disease (GERD): A condition whereby stomach acid comes up the esophagus regularly which causes irritation and may lead to esophageal cancer in the long run.

• Alcohol abuse.
• Cigarette smoking.
• Obesity.
• Suffering from Barrett’s esophagus: A condition whereby the cells lining the esophagus are precancerous.
• Suffering from achalasia: A condition whereby the sphincter located at the lower end of the esophagus, fails to open during swallowing.
• Unhealthy habit of drinking very hot liquids.
• Radiation therapy to the upper abdomen or chest.
• Insufficient consumption of fruits and vegetables.
• Consumption of red meat.
• Zinc deficiency.
• Prior gastrectomy: This is complete or partial removal of the stomach through surgery.
• Poor oral hygiene.
• Infections: The human papillomavirus (HPV) may contribute to the development of esophageal cancer.

What are the signs and symptoms of esophageal cancer?

The signs and symptoms of esophageal cancer include:

• Difficulty swallowing (dysphagia): Initially dysphagia is experienced for solids.  However, eventually is occurs even after ingestion of liquids.  This occurs when the esophageal diameter reduces.  Dysphagia is the most common symptom experienced by people affected by esophageal cancer.
• Weight loss: Weight loss usually occurs as a result of dysphagia and is the 2^nd most common symptom.
• Anaemia: This occurs as a result of continuous bleeding from the tumour.

• Pain: Pain in the upper abdomen may be associated with the disease.  In addition, pain over bony structure may indicated spreading of the disease.
• Hoarseness of voice: This usually occurs when the tumour spreads to affect the recurrent laryngeal nerve which is involved in speech production.  Unfortunately, this symptom indicates that the cancer has spread beyond the point at which surgical removal of the tumour is possible.
• Persistent cough.
• Enlarged lymph nodes: Enlarged lymph nodes in the neck indicate that the tumour can no more be removed via surgery.

Making a diagnosis

To make a diagnosis, your doctor will take a detailed history from your to know more about your symptoms.  After the history taking, your doctor will perform a physical examination to look for signs of esophageal cancer.  Unfortunately, history taking and physical examination only are not enough to make a diagnosis, therefore your doctor may order some tests to confirm the diagnosis and these include:

• Computed Tomography (CT) scan: CT scan of the abdomen and chest will help to exclude spread of the disease and may be helpful to determine which nearby structures have been affected.
• Positron Emission Tomography (PET) scan: PET scan is useful in determining whether the cancer has spread.
• Endoscopic ultrasound: This imaging technique is very helpful to determine the extent of spreading of the cancer.

• Barium swallow: This is a special type of x-ray whereby your doctor will ask you to drink a thick, chalky barium drink.  As you swallow, a series of x-rays will be taken to assess the esophagus.
• Upper gastrointestinal endoscopy: In this procedure, your doctor will insert a tube in your mouth which has a camera at its end in order to directly visualise the inside of your esophagus.  In addition, samples of the tumour may be taken during the procedure for analysis.
• Complete blood count (CBC): This is to assess whether your haemoglobin level is low which will indicate presence of anaemia.

What are the treatments of esophageal cancer?

The treatment options for esophageal cancer include:

• Surgery: If the tumour is very small, it can be removed during endoscopy.  If it is larger, your surgeon may remove the section of the esophagus containing the tumour and a small part of the stomach and this procedure is known as esophagectomy.  Then, the stomach is pulled upwards to meet the esophagus where they are stitched together. A stent may be placed endoscopically to relieved esophageal obstruction.
• Chemotherapy and radiotherapy: These treatment options are mainly used preoperatively to reduce the size of the tumour, facilitating its removal during surgery.
• Palliative care: People who are not candidates for surgery will obtain treatment focusing on relieving pain and improving quality of life.  Stents may be placed and radiotherapy may be used to reduce dysphagia.

What are the complications of esophageal cancer?

If esophageal cancer is left untreated, the following complications may ensue:

• Obstruction of the esophagus.
• Chronic pain.
• Bleeding from the tumour.

Complications associated with surgery include:

• Infection of the lungs (pneumonia).
• Abnormal heart rhythms.
• Myocardial infarction (MI) or heart attack.
• Surgical wound infection.
• Anastomotic leak: leakage of food contents from the connection made between the esophagus and the stomach during surgery.

Prognosis

The survival of people affected by esophageal cancer depends on the stage of the cancer.  In the year 2009-2015, the 5-year survival rate for esophageal cancer was 20%.  Esophageal cancer without lymph node involvement have a significantly better prognosis.  In addition, the 5-year survival rate was better in white than in blacks.  Seeking medical help early significantly improves the prognosis and prevent the occurrence of complications.

J. Alastair, I. and Simon, M., 2016. Davidson's Essentials of Medicine. 2nd ed. London: ELSEVIER.

Parveen, K. and Michael, C., 2017. Kumar & Clarks Clinical Medicine. 9th ed. The Netherlands: ELSEVIER

Masab, M., 2020. Esophageal Cancer.

Masab, M., 2020. Esophageal Cancer Treatment & Management