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Reviewed by Professor Alistair J Munro, professor of radiation oncology
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What is cancer of the oesophagus?
Cancer of the oesophagus or gullet develops as a result of cell
changes in the lining of the oesophagus.
There are two main types of cancer of the oesophagus: squamous
carcinoma, which is more common at the upper end of the gullet, and
adenocarcinoma, which is more common at the lower end, particularly around the
junction between the gullet and the stomach.
There has been a recent increase in the proportion of tumours
arising close to the junction of the stomach and gullet, but the reasons for
this are not yet known.
In a condition called Barrett's oesophagus, the lining of the
gullet becomes more like the lining of the stomach. Patients with Barrett's
oesophagus are at an increased risk of developing cancer of the oesophagus and
may benefit from regular follow-up and supervision by a doctor.
What causes cancer of the oesophagus?
It’s thought that
smoking and
alcohol, among other
things, can contribute to cancer of the oesophagus. (There’s some evidence that
spirits are the most dangerous type of alcohol to drink in connection with this
particular type of cancer.) This could account for the marked regional
variation within Europe. For example, cancer of the oesophagus is twice as
common in eastern Scotland as it is in the south of England.
There is also a particularly high rate in Normandy in France
which has been blamed on drinking Calvados, an apple brandy. It’s also 10 times
more common in southern China than in the UK. These differences are probably
related to diet as people in southern China eat a lot of heavily smoked and
salted fish.
In the UK,
iron deficiency used
to be a common cause of cancers in the upper gullet, particularly in women. But
with better diet and better medical care during
pregnancy, this
problem has now been virtually eliminated.
The disease is three times more common in men than in women and
is more common in people over the age of 60.
What are the symptoms of cancer of the oesophagus?
The first symptom of the disease is almost always difficulty in
swallowing. There is the feeling that food is getting stuck, often behind the
lower end of the breastbone. At first the problem is only with solid food but
later even semi-solids and liquids can cause problems.
Pain felt between the shoulder blades can also be troublesome.
This discomfort is sometimes triggered by eating.
Another characteristic symptom is regurgitating unaltered food a
few minutes after having difficulty swallowing the food. The patient often
tries to handle these problems by eating less and avoiding solid food. This
causes weight loss and
fatigue.
Later on,
heartburn, vomiting
and vomiting of blood may become the dominant symptoms. The early symptoms are
relatively minor and tend to creep up on patients. This means it is often
several months before they consult their doctors.
How is cancer of the oesophagus diagnosed?
It can be diagnosed by using
X-rays using special
dye. Before the X-ray picture is taken, the patient will be asked to swallow a
beaker of a whitish fluid called barium. X-ray pictures are taken as the barium
travels down the gullet and into the stomach.
The procedure is completely painless and provides valuable
information about the size of any abnormality present. It does not provide a
firm diagnosis though any irregular narrowing of the gullet would strongly
suggest that there may be a cancer present.
The definitive diagnosis is made through direct vision using a
camera attached to a flexible tube (an endoscope), which makes it possible to
take a tissue sample (biopsy). The
endoscopy (sometimes called a
gastroscopy) is
carried out while the patient is under sedation.
A long flexible tube, about the thickness of a fountain pen, is
passed through the mouth, over the back of the tongue and down into the gullet
and stomach. The tube is connected to a camera through which the doctor can
inspect the lining of the gullet and assess whether or not it is
normal.
A sample will be taken from any abnormal or suspicious areas.
After processing, these samples will be examined by a pathologist who will
decide whether or not there are any cancer cells present. It usually takes 7 to
10 days after the test before the pathologist's report is ready.
A
CT scan is often
performed to assess whether or not the disease has spread either locally or to
the
liver. This is a
particularly important investigation if surgery is being
considered.
How is cancer of the oesophagus treated?
Treatment may consist of surgery, radiotherapy,
chemotherapy or a
combination of these.
The best chance of cure is with surgery. Patients who are in
good general condition and who have small tumours have more than a 25 per cent
chance of cure with surgery.
In fit patients with more advanced disease, the combination of
chemotherapy and radiotherapy may be used - this can produce cure rates of
around 20 per cent. The combination is sometimes used to shrink tumours in
order to make subsequent surgery easier and more effective.
Unfortunately the majority of patients are not fit for intensive
treatment of this type. In their case treatment will be aimed simply at
relieving symptoms.
This can sometimes be done most easily using a stent. A stent is
simply a kind of tube that is inserted inside the gullet to help keep it open
and allow the passage of fluid and food. There are various kinds available,
ranging from a simple plastic tube to a device made of metal mesh that expands
once it has been put in place.
Stents can be put in place as a simple procedure at the same
time as an endoscopy is carried out.
Radiotherapy can also be used to try and shrink the tumour and
keep the gullet open for longer.
What is the prognosis?
Overall, the outlook is very poor. The five-year survival rate
for cancer of the oesophagus is less than 10 per cent. Survival rates are
higher in younger patients who are fit enough for intensive treatment, with
cure rates of 20 per cent or more.
Reference
http://info.cancerresearchuk.org/cancerstats/types/oesophagus/survival/
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Based on a text by Dr Per Grinsted, GP
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Last updated 05.09.2008
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