Esophageal cancer

Symptoms Of Esophageal Cancer 

• Difficulty in swallowing (dysphagia)

• Pain or discomfort in the throat or back

• Chest pain or discomfort, particularly when eating or swallowing

• Frequent heartburn or acid reflux

• Chronic cough

• Hoarseness of voice

• Regurgitation of food or blood

• Vomiting, sometimes with blood

• Frequent hiccups

• Tiredness

• Unintentional weight loss

Note: Symptoms of esophageal cancer can differ from person to person, and some may not appear until the cancer is advanced.

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Types of Esophageal Cancer

There are 2 main types of esophageal cancer, based on the type of cell involved. They include:

1. Adenocarcinoma

• This is the most common type of esophageal cancer that starts in glandular cells (cells that form glands) near the stomach

2. Squamous cell carcinoma

• This esophageal cancer originates from upper cells that line the inner surface of the esophagus.

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Causes Of Esophageal Cancer

Esophageal cancer affects the tubular passage connecting the mouth to the stomach and primarily originates in the mucosa, the moist lining of the esophagus.

Here's an overview of what happens during cancer:

• DNA, the genetic material, governs cell behaviour, growth, division, and cell death.

• Some genes oversee the timing of cell growth, division, and death like:

  • Oncogenes promote cell growth, division, and survival.

  • Tumor suppressor genes regulate cell division and trigger cell death when necessary.

• Esophageal cancer can stem from DNA mutations that activate oncogenes or deactivate tumor suppressor genes, leading to uncontrolled cell growth and abnormal mass formation in the esophagus.

• Several factors can increase the likelihood of developing esophageal cancer, which is discussed in detail in the next segment.

Risk Factors For Esophageal Cancer

Esophageal cancer, like many other types of cancer, has several risk factors that may increase the likelihood of developing the disease. The primary risk factors for esophageal cancer include:

1. Age

The risk of esophageal cancer increases with age, and it is more commonly diagnosed in older adults between the ages of 45 and 70 years.

2. Gender

Men are more likely to get esophageal cancer than women.

3. Family or personal history of cancer

Individuals who have had head and neck cancer or esophageal cancer in the past may have a higher risk of developing esophageal cancer. Positive family history of cancer can also increase the risk.

4. Medical conditions

• Gastroesophageal reflux disease (GERD)

• Barrett's esophagus (a condition where the normal lining of the esophagus is replaced by a tissue that is similar to the lining of the intestine)

• Plummer-Vinson syndrome (characterized by a triad of symptoms: iron deficiency anemia, difficulty swallowing (dysphagia), and esophageal web formation)

5. Lifestyle choices

• Obesity

• Physical inactivity

• Tobacco smoking 

• Alcohol use 

• Diet rich in processed, packaged food, red meat and low in fruits and vegetables.

• Consumption of very hot liquids

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6. Other factors

• Achalasia (a rare disorder where the muscular ring between the esophagus and stomach, fails to relax properly)

• Human papillomavirus (HPV) infection

• Injury to the esophagus.

Diagnosis Of Esophageal Cancer

To arrive at the diagnosis of any kind of cancer, it is important to understand its staging. Staging is essential to determine the extent of the disease.

Staging of esophageal cancer

The primary staging system used is the TNM system, which evaluates:

• T (Tumor): This indicates how deeply the tumor has invaded the layers of the esophagus wall and the surrounding tissue.

• N (Lymph Nodes): It assesses whether cancer has spread to nearby lymph nodes and, if so, how close they are to the original tumor.

• M (Metastasis): This assesses whether cancer has spread to other parts of the body.

Based on these criteria, esophageal cancer is categorized into the following stages:

• Stage 0 ( Carcinoma in situ): Abnormal cells are present in the top layers of the esophagus, which could develop into cancer in the future.

• Stage 1: At this stage, cancer is confined to the thick muscle layer of the esophageal wall and hasn't spread beyond.

• Stage 2: The cancer has penetrated deeper layers of the esophagus and may have affected nearby lymph nodes.

• Stage 3: Cancer cells are found in all layers of the esophagus and may have also spread to adjacent organs.

• Stage 4: Cancer has spread to distant organs or lymph nodes, often the liver, and lungs, or distant lymph nodes.

The diagnostic process may include the following steps:

1. Medical History and Physical Examination

The first step in diagnosing esophageal cancer is discussing your medical history and symptoms with a healthcare provider. They will perform a physical examination to check for any signs of the disease.

2. Imaging Tests

• CT scan: A computed tomography (CT) scan provides detailed cross-sectional images of the chest and abdomen, which can help determine the extent of the cancer and identify nearby lymph node involvement.
  
  
• PET scan: A positron emission tomography (PET) scan is used to detect areas of increased metabolic activity, which can indicate the spread of cancer.
  
  
• Barium swallow test: This test helps identify any abnormalities in the esophagus, such as tumors or strictures (webs). You will be asked to drink a contrast material containing barium, which is visible on X-rays. 

3. Endoscopy

It is a procedure using a flexible tube with a camera to check the body. It helps diagnose and assess esophageal cancer. It includes:

• Upper endoscopy: It also helps determine tumor size and spread, vital for surgery planning.
  
  
• Endoscopic ultrasound: Used to measure cancer size and spread into nearby areas. It can also check lymph nodes for cancer.
  
  
• Bronchoscopy: It may be performed to check if esophageal cancer has spread to the windpipe or lung tubes.
  
  
• Thoracoscopy and laparoscopy: Thoracoscopy examines the chest cavity, while laparoscopy examines the abdomen. 

4. Cytology

• Brush cytology: This is a technique where cells from the esophagus lining are brushed and examined under a microscope to check for abnormalities. 
  
  
• Balloon cytology: In this procedure, the person swallows a deflated balloon, which is later inflated and pulled out to collect esophageal cells for analysis

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5. Biopsy

Tissue samples taken during the endoscopy are sent to a pathology laboratory to be analyzed by a pathologist. This is a definitive way to confirm the presence of cancer, identify its type (adenocarcinoma or squamous cell carcinoma), and assess its grade and stage.

6. Blood Tests

• Complete blood count (CBC): This test measures the different types of cells in your blood. It can identify signs of anemia. Esophageal cancer may induce anemia through bleeding tumors and affect liver function if it spreads.
  
  
• Liver function test: A blood test to check your liver function because esophageal cancer can sometimes spread to the liver.

7. Biomarker testing of the tumor

• HER2 testing:  In advanced esophageal cancer, doctors may test biopsy samples for HER2. This protein can make cancer grow faster. This testing can be used in targeted drug therapy.
  
  
• PD-L1 testing: Some esophageal cancers are assessed for the PD-L1 protein level, as tumors with more PD-L1 may respond better to immunotherapy drugs.
  
  
• MMR and MSI testing: Testing is done to check for high levels of microsatellite instability (MSI) or changes in mismatch repair (MMR) genes in esophageal cancer cells. Positive results might indicate suitability for immunotherapy in cases where surgery is not an option or the cancer has recurred or spread.
  

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Prevention Of Esophageal Cancer

Preventing esophageal cancer involves adopting a combination of lifestyle changes and risk-reduction strategies. Here are some preventive measures:

1. Break free from smoking

Smoking is a significant risk factor for esophageal cancer, particularly squamous cell carcinoma. You can greatly lower your risk by giving up smoking.

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2. Cut down on alcohol

Drinking too much alcohol raises the risk of esophageal cancer, so it's best to avoid it or limit intake to one drink daily for women and two for men. 

3. Be mindful of your diet

Consume 

• A balanced diet rich in fruits and vegetables such as berries, citrus fruits, leafy greens, broccoli, and carrots). 

• A diet high in fiber and antioxidants 

• Rich sources of omega-3 fatty acids like fish, chia seeds, walnuts, flax seeds, eggs, etc.

Avoid 

• Highly processed food 

• Sugary snacks and drinks 

• Fast food

• Pre-packaged food loaded with chemicals and preservatives

• Red meat

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4. Watch your weight

Being obese increases the risk of esophageal adenocarcinoma, but maintaining a healthy weight with a balanced diet and regular exercise can help lower this risk.

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5. Manage acid reflux 

Avoid trigger foods, elevate the head of your bed, and consult a doctor if symptoms persist as gastroesophageal reflux disease (GERD) increases the risk of esophageal adenocarcinoma.

6. Screen for early detection

If you are at a high risk for esophageal cancer, talk to your healthcare provider about regular screening.

7. Try chemoprevention

Some studies suggest that regular, long-term aspirin use may reduce the risk of esophageal cancer, particularly in those with Barrett's esophagus. Talk to your doctor before starting regular NSAID use.

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Doctor To Visit

Cancer requires comprehensive care. Doctors who help in diagnosing and formulating a treatment plan are:

• General physician
• Gastroenterologist
• Oncologist
• Surgical oncologist
• Hepatologist
  

A general physician can do a detailed clinical examination, suggest tests, and refer to a specialist in case they suspect esophageal cancer.

A gastroenterologist diagnoses and monitors esophageal cancer using endoscopy and biopsies, managing digestive tract-related symptoms.

An oncologist is specialized in cancer treatment, they design and oversee esophageal cancer treatment plans, including chemotherapy, radiation, and targeted therapies.

A surgical oncologist performs tumor-removing surgeries, like esophagectomy, crucial for some esophageal cancer cases.

A hepatologist focused on liver issues and offers expertise when esophageal cancer spreads to the liver.

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Treatment Of Esophageal Cancer

Here's an overview of the treatment options for esophageal cancer:

I. General treatment measures

1. Palliative care

It focuses on providing relief from the symptoms and side effects of cancer, improving the patient's quality of life, and managing pain. 

2. Nutrition therapy

Esophageal cancer can disrupt normal nutrition intake, leading to malnutrition and dehydration. Your treatment strategy may involve a phase of body recovery and fortification before addressing the cancer itself.

Note: Dietitians can help with customized diets for swallowing issues and may recommend intravenous nutritional therapy to provide essential nutrients directly into your bloodstream.

II. Local Treatment

1. Surgery

• Esophagectomy: This is the most common surgical procedure for esophageal cancer. It involves removing part or all of the esophagus and then reconstructing it. The choice of surgery depends on the location and extent of the tumor.
  
  
• Lymph node dissection: During surgery, nearby lymph nodes are often removed and examined to determine if the cancer has spread.

2. Radiation therapy

Radiation therapy uses high-energy X-rays or other particles to target and destroy cancer cells. It is of two types:

• External-beam radiation therapy: The most popular kind of radiation therapy, in which radiation is administered externally to the body via a machine. 
  
  
• Internal-beam radiation therapy (brachytherapy): When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. Brachytherapy involves the application of a radioactive source near the tumor. 

3. Endoscopic treatment

• Endoscopic mucosal resection: Used for dysplasia (pre-cancer) and early-stage esophageal cancers. Involves removing abnormal tissue with instruments passed through the endoscope.
  
  
• Photodynamic therapy (PDT): Used for Barrett's esophagus, dysplasia, early-stage esophageal cancers, and to relieve obstruction in advanced cancers. Involves injecting a light-activated drug that accumulates in cancer cells. Laser light activates the drug to kill cancer cells, which are removed during endoscopy.
  
  
• Radiofrequency ablation (RFA): A balloon with electrodes is inserted via endoscopy and delivers an electrical current to kill abnormal cells. Normal cells replace the treated area over time.
  

4. Treatments to keep the esophagus open

• Laser ablation: Uses a laser beam through an endoscope to open a blocked esophagus due to advanced cancer. Often requires repeated procedures.
  
  
• Argon plasma coagulation: Similar to laser ablation but uses high-temperature argon gas and a spark. Used for esophageal blockage relief.
  
  
• Electrocoagulation (electrofulguration): Burns tumors off with electric current, helpful for relieving esophageal blockage.
  
  
• Esophageal stent: A mesh device placed into the esophagus to keep it open. Typically made of metal or plastic and used after other endoscopic treatments.

III. Systemic treatment 

1. Chemotherapy

Chemotherapy (chemo) is treatment with anti-cancer drugs that are injected into a vein or taken by mouth, which allows them to enter the blood and reach most parts of the body. Drugs used for chemotherapy include:

• Carboplatin 
• Paclitaxel 
• Oxaliplatin 
• Capecitabine
• Cisplatin
• 5-fluorouracil (5-FU)

Types of chemotherapy include:

• Adjuvant chemotherapy: It is given after surgery and is sometimes coupled with radiation therapy. In addition to preventing recurrence, the objective is to eradicate any cancer cells that may have been left behind after surgery due to their smaller size.
  
  
• Neoadjuvant or induction chemotherapy: This is used prior to surgery, either with or without radiation, this helps reduce the size of some bigger malignancies so that less tissue is removed during surgery. This may result in less severe surgical side effects and issues.
  
  
• Chemo for advanced cancers: Chemotherapy can also be used to reduce tumor size and alleviate symptoms in cancers that have progressed to other organs, like the liver. Therapy frequently prolongs people's lives, even if therapy is unlikely to cure the cancer.
  
  
• Chemoradiation: By itself, chemo rarely cures esophageal cancer so it is often given with radiation therapy.

2. Targeted therapy

It is the use of medicines that are designed to target specific molecules or proteins involved in cancer cell growth. These therapies may be used in cases of advanced or metastatic esophageal cancer. Some targeted drugs include:

• Trastuzumab
• Ramucirumab
• Entrectinib
• Larotrectinib
  

3. Immunotherapy

This therapy uses medicines to help boost a person’s own immune system to find and destroy cancer cells more effectively. It typically works on specific proteins involved in the immune system to enhance the immune response. Drugs used are:

• Pembrolizumab
• Nivolumab
  

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Home-care For Esophageal Cancer

Caring for esophageal cancer at home includes adjusting your diet to aid recovery and manage post-surgery challenges. While some herbs and spices may support cancer management, they should never replace medical treatment—always consult your doctor first. These include:

1. Aloe vera: Some studies suggest that aloe vera may help reduce inflammation and enhance the immune system, which can be beneficial for cancer patients.

How to consume: It can be consumed in various ways, such as in the form of aloe vera juice or supplements. 

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2. Ginger (Adrak): It has anti-inflammatory and antioxidant properties, which can help alleviate nausea and vomiting, common side effects of cancer treatments like chemotherapy.

How to consume: It can be consumed in various forms, including fresh ginger root, ginger tea, ginger supplements, or as an ingredient in cooking.

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3. Turmeric (Haldi): It contains an active compound called curcumin that has shown potential in slowing the growth of cancer cells and inhibiting the spread of cancer in preclinical studies. It can also help manage inflammation and alleviate symptoms.

How to consume: It can be consumed as a spice in cooking, taken as a supplement, or in the form of turmeric tea. 

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Complications Of Esophageal Cancer

Esophageal cancer can lead to various complications, including:

1. Functional gastric emptying disorder: Following surgery or treatment, individuals may experience difficulties with the normal emptying of the stomach.

2. Severe diarrhea and reflux esophagitis: Treatment and surgery for esophageal cancer can cause digestive issues, including severe diarrhea and gastroesophageal reflux disease (GERD), resulting in acid reflux and inflammation of the esophagus.

3. Pulmonary infection: As food or liquids are aspirated into the lungs due to swallowing difficulties, it can result in pulmonary infections, potentially leading to pneumonia and other respiratory issues.

4. Chylothorax:  It is the accumulation of lymphatic fluid (chyle) in the chest cavity that can occur in some cases, leading to breathing difficulties.

5. Anastomotic fistula: This is a condition where a surgical connection (anastomosis) between two parts of the digestive tract, typically the esophagus and stomach, may develop a leak or fistula, leading to infection and further surgical interventions.

6. Complications from treatment: Chemotherapy, radiation therapy, and surgery can have their own set of complications, including infection, scarring, and long-term side effects.

Note: Advanced stages may result in cancer spreading to vital organs such as the liver, lungs, bones, adrenal glands, kidneys, and brain via the bloodstream.

Alternative Therapies For Esophageal Cancer

Complementary and alternative therapies can be considered alongside conventional medical treatments for esophageal cancer after consultation with your medical team. Some complementary therapies may include:

1. Acupuncture

It involves the insertion of needles through the skin at specific points on the body. Acupuncture has proven to be a successful alternative therapy form for patients who have esophageal cancer that can ease symptoms such as nausea and vomiting, which are common side effects of cancer treatments.

2. Aromatherapy

It utilizes essential oils to alleviate pain, nausea, stress, and sleep difficulties during cancer treatment, promoting relaxation and comfort.

3. Hypnosis

It is carried out by a therapist who will help you through certain relaxation exercises that can encourage positive and relaxing thoughts. It also helps in reducing nausea and anxiety seen in people with cancer. 

4. Yoga

Yoga practices, including breathing techniques, gentle movement, mindfulness, and meditation, can optimize healing and well-being, promoting physical and emotional balance.

5. Music therapy

Listening to calm and soothing music can promote healing and improve the quality of life.

6. Tai chi

A mind-body system that improves health and well-being through movement, meditation, and breathing. It has been shown to help some people improve their strength and balance alleviating cancer symptoms.

Living With Esophageal Cancer

Living with cancer means different things to different people. Things that the caregiver and the patient should take into consideration include:

1. Managing the emotions

Individuals with cancer may feel turmoil of emotions such as sadness, anxiety, or anger, or difficulty in managing the stress level. Tips that can help:

• Get all the information needed to go about with the treatment

• Talk to the loved ones

• Join support groups

• Start palliative care to get relief from other symptoms

• Take help in coping with practical issues like financial expenses, childcare, and work issues.

2. Post-surgery diet guidelines

• Opt for 6 small meals post-esophageal cancer surgery to accommodate reduced stomach capacity.

• Start with ½ to 1 cup portions, gradually increasing; prioritize nutrient-dense, high-calorie, and high-protein foods.

• Chew thoroughly, eat slowly to prevent overeating, and limit liquid intake during meals to ½ cup.

• Consume liquids 1 hour before/after meals, aim for 8-10 glasses daily, and avoid carbonated drinks causing fullness

• Embrace a high-calorie, protein-rich diet with foods like dairy, nuts, meats, and eggs for optimal nutrition

3. Surviving the symptoms

• Manage reflux post-esophageal surgery: Sit up during meals, wear loose clothes, eat 2 hours before bedtime, and elevate upper body during sleep.
  
  
• Combat nausea: Avoid rich foods, eat moderately, and resting in a slightly slanted position after meals.
  
  
• Handle fullness: Watch for signs, limit meal sizes, eat slowly, and establish a schedule for smaller, frequent meals.
  
  
• Take care of diarrhea: Gradually reduce sugar, dairy, and fat; include soluble fiber-rich foods; prioritize food safety.
  
  
• Ease swallowing issues: Choose soft, moist foods, and chew thoroughly to aid swallowing.

4. Supervising the cost of cancer care

• Cancer treatment can be expensive and coping financially can become a source of stress and anxiety for patients and their families. 

• In addition to treatment costs, there might be extra unplanned expenses as well.

• This can be managed by asking the social worker about benefits or grants, they can also help with the claiming process.

Tips for caregivers

• Encouraging and providing mental support to the patient

• Helping the patient manage their symptoms and side effects

• Coordinating their medical appointments and giving medications on time

• Assisting the patient in maintaining personal care and hygiene

• Talking with empathy and a positive attitude toward the patient

• Helping the patients with household chores

• Handling insurance and billing issues for them

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