Esophageal Cancer

The esophagus is the hollow, muscular tube that carries food and liquids from the throat to the
stomach. It is part of the digestive system and is located between the windpipe (trachea) and the spine.
In adults, the esophagus is about 10 inches long. Esophageal cancer usually originates in the lining of
the esophagus (called the mucosa) and can develop in the upper, middle, or lower section of the organ.

The most common types of esophageal cancer are squamous cell carcinoma and
adenocarcinoma. Squamous cell carcinoma develops in flat cells that line the esophagus.
Approximately 60% of squamous cell carcinomas develop in the middle third of the organ, 30%
occur in the lower third, and 10% occur in the upper third.

Adenocarcinoma develops in the lining of the esophagus and is associated with a condition called
Barrett's esophagus. This type usually occurs in the lower third of the esophagus.

Incidence and Prevalence

According to the National Cancer Institute (NCI), esophageal cancer is the third most common cancer
of the digestive tract and the seventh leading cause of cancer-related deaths worldwide. Overall
incidence of the disease is highest in men over the age of 50.

Incidence of esophageal cancer varies considerably according to geographic location. It is more

common in northern China, northern Iran, and southern republics of the former Soviet Union, and is

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less common in Japan, Great Britain, Europe and Canada. In the United States, incidence is highest in
urban areas and overall incidence is about 5 in 100,000.

Squamous cell carcinoma of the esophagus accounts for most cases worldwide and about 40% of cases
in the United States. This type is more common in African American men and is associated with
cigarette smoking and high intake of alcohol.

According to the NCI, incidence of adenocarcinoma of the esophagus, which is associated with
Barrett's esophagus, is rising in the United States. This type is more common in Caucasian men over the
age of 60.

Causes and Risk Factors

Esophageal cancer is caused by a malignant change (mutation) in cells that comprise the lining of the
esophagus. Esophageal tumors often invade the submucosa (i.e., layer of connective tissue) and then
the muscular layer of the organ.

Age increases the risk for esophageal cancer and the disease is more common after the age of 50. Risk
for developing cancer of the esophagus is about 3 times higher in men.

Other risk factors include medical conditions such as the following:

• Achalasia (rare disease that affects the muscles of the esophagus)

• Helicobacter pylori infection (associated with gastritis and peptic ulcer disease)
• Human papillomavirus (HPV) infection (may increase risk in high-incidence areas)
• Plummer-Vinson syndrome (also called Patterson-Kelly syndrome; characterized by
anemia, brittle fingernails, and esophageal irritation)
• Prior history of other head and neck cancers
• Tylosis (rare, genetic, skin disorder that causes esophageal inflammation)

Recent studies indicate that esophageal cancer may have genetic (hereditary) risk factors. A number of
genes have been identified that may increase the risk for the disease. Additional research is necessary
to determine genetic risk factors for cancer of the esophagus.

Squamous Cell Carcinoma

In the United States, major risk factors for squamous cell carcinoma of the esophagus include heavy
alcohol consumption, tobacco use (e.g., cigarette smoking, chewing tobacco), and previous caustic
injury (e.g., ingesting lye). Risk for the disease is nearly 100 times greater when heavy alcohol use and
smoking are combined.

In developing countries, major risk factors for this type of esophageal cancer include the following:

• Nutritional deficiency associated with lack of fresh fruits and vegetables

• Regular consumption of very hot beverages
• Regular ingestion of fermented vegetables
• Smoking and chewing tobacco

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Environmental risk factors for squamous cell carcinoma include exposure to asbestos,
perchlorethylene (common dry cleaning solvent), and fuel-burning appliances (e.g., space heaters,
fireplaces, stoves).

Adenocarcinoma
Barrett's esophagus is the primary risk factor for adenocarcinoma of the esophagus. In this condition,
tissue damage in the lining of the esophagus occurs as a result of chronic gastroesophageal reflux disease
(GERD). About 10% of patients with GERD develop Barrett's esophagus and about 1% of these
patients develop esophageal cancer. The most common symptom of GERD is frequent heartburn.

Obesity also is a risk factor for adenocarcinoma of the esophagus.

Signs and Symptoms

Early cancer of the esophagus is usually asymptomatic (i.e., does not cause symptoms). In as many as
50% of cases, the disease is locally advanced or has already spread (metastasized) at the time of
diagnosis. Symptoms of the disease include the following:

• Coughing up blood
• Difficulty swallowing (dysphagia) or painful swallowing (odynophagia)
• Hoarseness or chronic cough
• Iron-deficiency anemia (may be diagnosed through a blood test)
• Pain in the throat, back, behind the breastbone (sternum), or between the shoulder blades
• Severe weight loss
• Vomiting

Diagnosis
Diagnosis of esophageal cancer involves a medical history (including information about symptoms
[especially difficulty swallowing and weight loss], existing medical conditions [e.g., GERD], and
alcohol and tobacco use), physical examination, and medical tests.

Because esophageal cancer tends to spread first to the lymph nodes, physical examination
includes palpating (i.e., feeling with the fingers) the lymph nodes to check for enlargement. If the
physician suspects lymph node involvement, a needle aspiration (i.e., removal of cells for
microscopic evaluation) or biopsy may be performed.

Blood tests may include a complete blood count (CBC) and liver function tests. CBC is used to
detect anemia and liver function tests are used to detect liver metastasis and abnormalities
caused by a high intake of alcohol.

Imaging tests used to diagnose esophageal cancer include a chest x-ray and a double-contrast
barium swallow. In double-contrast barium swallow, the patient drinks a solution that
contains barium, which is a dense liquid that appears white on x-rays. Then, air is blown into the
esophagus to help the liquid coat the wall of the organ more thoroughly. Esophageal tumors
cause the barium to coat the esophagus unevenly, which shows up on x-ray.

Imaging tests used to determine the extent of the disease and to detect metastasis include the following:
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 • Bone scan (to detect bone metastasis)
• Bronchoscopy (to determine if cancer has invaded the trachea [windpipe] or bronchi
[tubes leading from the trachea to the lungs]; performed under sedation)
• CT scan
• Endoscopic ultrasound (to determine the size of the tumor and the extent of spread into
nearby tissue)
• Positron emission tomography (PET; used to detect metastasis and to help stage the
disease)

When esophageal cancer is suspected, an esophagoscopy usually is performed. In this test, a thin tube
with a light and camera attached (called an endoscope) is passed into the esophagus to allow the
physician to visualize the mucosa (i.e., the lining) and detect abnormalities. Small instruments may be
passed through the endoscope and used to remove a sample of tissue for microscopic examination
(called a biopsy).

Once esophageal cancer is diagnosed, the stage of the disease is determined.

Staging
The staging system for esophageal cancer conforms with the Tumor, Node, Metastasis System of
the American Joint Committee on Cancer.

Stages of the tumor:

T1: The tumor is only in lining of the esophagus.
T2: The tumor has moved into the layer of muscles in the esophageal wall.
T3: The tumor has advanced through the entire esophageal wall.
T4: The tumor has affected nearby tissues.
Stages of spread to lymphatic system:
NX: Doctors cannot determine if cancer extends to nearby lymph nodes.
N0: Cancer has not extended to nearby lymph nodes.
N1: Cancer has extended to nearby lymph nodes.
Metastasis
The lymphatic system can transport cancer cells to distant parts of the body, where they can
grow into new tumors. This is the process of metastasis. Another aspect of staging classifies
cancers based on the extent to which they have metastasized:
MX: Doctors cannot determine if metastasis has taken place.
M0: Metastasis has not taken place.
M1: Metastasis has taken place.
Stage Groupings
Stage I: T1 N0 M0
Stage IIA: T2 N0 M0 or T3 N0 M0
Stage IIB: T1 N1 M0 or T2 N1 M0
Stage III: T3 N1 M0 or T4 any N M0
Stage IV: any T any N M1

Treatment
Treatment depends on the stage of the cancer and the overall health of the patient. Surgery,
radiation, and chemotherapy may be used alone or in combination to treat cancer of the
esophagus. Chemotherapy and/or radiation often are used as adjuvant treatments (i.e., in
addition to surgery) and may be used to reduce symptoms (called palliative treatment).

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Surgery
Esophagectomy (removal of all or part of the esophagus) is the treatment of choice for
esophageal cancer. This procedure also includes removal of nearby lymph nodes and surrounding
tissue. Transhiatal esophagectomy is performed through incisions in the upper abdomen and the
lower neck and standard transthoracic esophagectomy is performed through an incision between
the ribs that opens one side of the chest. In some cases, the surgeon attaches the healthy
remaining portion of the esophagus to the stomach (anastomosis), and in other cases, a section
of the intestine is used.

Contraindications for surgery include metastatic disease, tumor invasion of nearby structures
(e.g., trachea, bronchi, aorta, pericardium), and severe cardiovascular or pulmonary disease.

After surgery, most patients are discharged from the hospital within 14 days. Side effects of the
procedure include pain and tenderness, which usually can be controlled with medication. Patients
are instructed to use special breathing and coughing exercises to help keep their lungs clear. Most
patients are able to resume normal activities within 2 months.

Complications may be severe and occur in about 40% of patients. They include the following:

• Anastomotic leakage
• Bleeding
• Cardiac complications (e.g., arrhythmia, heart attack)
• Infection at the incision site or throughout the body (sepsis)
• Nerve injury
• Pulmonary complications (e.g., chylothorax, pneumonia, pleural effusion)

Radiation Therapy
Radiation involves using high-energy x-rays to destroy cancer cells. This treatment often is
combined with chemotherapy to reduce dysphagia (difficulty swallowing) in patients with
advanced or metastatic esophageal cancer. It also may be used to shrink the tumor before
surgery (neoadjuvant therapy) or after surgery to destroy remaining cancer cells (adjuvant
therapy).

Radiation therapy is performed in a hospital or outpatient center. Each treatment lasts a few
minutes and treatment is usually given 5 days per week, for 6 weeks. Side effects include the
following:

• Dental cavities
• Difficulty swallowing
• Dry, sore mouth and throat
• Fatigue
• Loss of appetite
• Reddening of the skin
• Swelling of the mouth and gums

Chemotherapy
Chemotherapy uses a combination of drugs to destroy cancer cells. It is a systemic treatment
(i.e., affects cells throughout the body) and may be used in combination with radiation to relieve
symptoms. It is not used as a primary treatment for esophageal cancer. Common side effects
include the following:

• Diarrhea
• Fatigue
• Hair loss
• Loss of appetite

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 • Mouth and lip sores
• Nausea and vomiting
• Skin rash and itching

Prognosis

Prognosis for esophageal cancer depends on the stage of the disease. Advanced disease (i.e., penetrates
the muscular wall of the organ) and metastatic esophageal cancer have a poor prognosis. The overall 5-
year survival rate for esophageal cancer is 20-25%.

Prevention

Avoiding heavy alcohol consumption and tobacco use may help prevent squamous cell carcinoma of
the esophagus. In developed countries, these factors contribute to as many as 90% of cases.

Patients with frequent heartburn should undergo regular endoscopic screening to detect precancerous
changes in the lining of the esophagus, which are the primary risk factor for adenocarcinoma of the
esophagus. Dietary and lifestyle changes and medication may help prevent progression of Barrett's
esophagus.

Esophageal Cancer
Definition of esophageal cancer: Cancer that forms in tissues lining the esophagus (the muscular tube
through which food passes from the throat to the stomach). Two types of esophageal cancer are squamous cell carcinoma
(cancer that begins in flat cells lining the esophagus) and adenocarcinoma (cancer that begins in cells that make and release
mucus and other fluids).

Q. What is the Oesophagus?

A. The oesophagus is the proper name for your gullet, the tube running from your mouth down to your
stomach. It lies between your windpipe and your spine.

Q. What is cancer of the oesophagus?

A. There are two main types of oesophageal cancer. Cancers found in the upper two-thirds of the
oesophagus are usually squamous carcinomas. Cancers of the lower third are usually adenocarcinomas.
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These two types of cancers have different types of cells, almost certainly have different causes and need to
be treated differently.

Q. How common is oesophageal cancer?

A. Each year there are nearly 15,000 new cases of oesophageal cancer in the USA, nearly 1500 in Canada,
nearly 1200 in Australia and 6,000 in the UK. Some countries, such as Turkey, China, India and South
Africa have very high rates of this type of cancer. Even within Europe there is a wide variation. The rate in
the UK and Ireland is ten times higher than in Greece and Spain. The incidence of adenocarcinoma of the
oesophagus has been increasing over the last 20 years, particularly amongst males in Europe and North
America.

Q. Who is more likely to get adenocarcinoma of the oesophagus ?

A. The main risk of adenocarcinoma of the oesophagus comes from a condition called Barrett's oesophagus.
This is a type of heartburn, caused by long-term gastric reflux - the stomach contents splashing up into the
lower part of the gullet. About one person in a hundred suffers from Barrett's oesophagus. They are up to
50 times more likely to get oesophageal cancer then normal. The more severe the case of Barrett's
oesophagus, the greater the risk of cancer. Barrett's oesophagus is about three times more common in men
than women and cancer of the oesophagus is twice as common in men as women. Like most cancers,
oesophageal adenocarcinoma is more common in older people: the majority of cases are diagnosed in people
over 65. Whites are more likely to get this type of cancer then blacks. Higher risk of this cancer has also
been associated with smoking, obesity and a diet low in fruit and vegetables.

Q. Who is more likely to get squamous carcinoma of the oesophagus?

A. Smoking and excessive alcohol consumption substantially increase the risk of this type of oesophageal
cancer. Indeed, smoking is thought to be responsible for four in every ten cases. Blacks are more likely to
get this cancer than whites. Eating certain preserved and pickled foods, common in China and Iran, have
also been linked to a higher risk.

Q. What are the symptoms of oesophageal cancer?

A. Early oesophageal cancer does not cause any symptoms, which means that most cases are quite
advanced when diagnosed. By far the most common symptom of oesophageal cancer is difficulty
swallowing, often with the feeling that the food is getting stuck in the throat. Other, less common
symptoms include persistent hiccups or coughing, weight loss, indigestion and vomiting.

Q. Is there screening for oesophageal cancer?

A. There is no routine screening for oesophageal cancer, but people who have a high risk (eg people with
Barrett's oesophagus) should have an endoscopic examination every year (see below).

Q. How is oesophageal cancer diagnosed?

A. The main technique used for diagnosis is called endoscopy. Under sedation, a thin fibre-optic tube (the
endoscope) is passed down the throat. The inside of the oesophagus is lit up and photographed. Any
growths can be spotted relatively easily by this method. A type of endoscope which can take a small sample
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of the oesophageal lining (a biopsy) is often used. Sometimes, a barium meal is used instead of endoscopy.
The patient is given a white liquid to drink, containing the element barium, then the throat is observed
through an X-ray screen. The way that the barium flows through the oesophagus will reveal any growths.
If the endoscopy or barium meal reveals a tumour, a CT or ultrasound scan will normally be done to find out
if the cancer has spread.

Q. How is oesophageal cancer treated?

A. Surgery is the main form of treatment for oesophageal cancer. For early cancers that have not spread,
the surgeon removes the section of the oesophagus with the cancer. Usually the remaining part of the
oesophagus is reconnected to the stomach. However, if the cancer has spread, part of the stomach may
have to be removed as well, so the shortened oesophagus is connected to a smaller stomach. Sometimes,
patients will be given drug treatment (chemotherapy) to shrink the tumour before the operation. In other
cases, where the cancer is so advanced that it cannot be cured, chemotherapy or radiation treatment may
be used to reduce the symptoms.

Q. How successful are the treatments?

A. If the cancer is diagnosed early, the treatments have a reasonable chance of success. In the USA, nearly
one third of patients live for five years after they have been diagnosed and treated. However, most cases
are not diagnosed early and, overall, only one in seven of oesophageal cancer patients survive for five
years. In some countries, including the United Kingdom, that figure is as low as one in fourteen.

Cancer of the Oesophagus

Cancer of the oesophagus is uncommon in the UK. Most cases occur in people over
the age of 50. Those diagnosed at an early stage have the best chance of a cure. In
general, the more advanced the cancer (the more it has grown and spread), the less
chance that treatment will be curative. Most cases are diagnosed when the cancer is
advanced. However, treatment can often slow the progress of the cancer or ease
symptoms.

What is the oesophagus?

The oesophagus (gullet) is part of the gastrointestinal tract (the gut). When we eat, food passes down the
oesophagus into the stomach. The upper section of oesophagus lies behind the windpipe (trachea). The lower
section lies between the heart and the spine.

There are layers of muscle in the wall of the oesophagus. These contract to propel food down into the stomach.

There is a thickened circular band of muscle (a 'sphincter') at the junction between the oesophagus and
stomach. This relaxes to allow food down, but normally tightens up and stops food and acid leaking back up
(refluxing) into the oesophagus. In effect the sphincter acts like a valve.

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 What is cancer?

Cancer is a disease of the cells in the body. The body is made up from
millions of tiny cells. There are many different types of cell in the body,
and there are many different types of cancer which arise from different
types of cell. What all types of cancer have in common is that the
cancer cells are abnormal and multiply 'out of control'.

A malignant tumour is a 'lump' or 'growth' of tissue made up from

cancer cells which continue to multiply. As they grow, malignant
tumours invade into nearby tissues and organs which can cause
damage.

Malignant tumours may also spread to other parts of the body. This
happens if some cells break off from the first (primary) tumour and are
carried in the bloodstream or lymph channels to other parts of the
body. These small groups of cells may then multiply to form
'secondary' tumours (metastases) in one or more parts of the body.
These secondary tumours may then grow, invade and damage nearby
tissues, and spread again.

Some cancers are more serious than others, some are more easily treated than others (particularly if diagnosed
at an early stage), some have a better outlook (prognosis) than others.

So, cancer is not just one condition. In each case it is important to know exactly what type of cancer has
developed, how large it has become, and whether it has spread. This will enable you to get reliable information
on treatment options and outlook. See separate leaflet called 'What are Cancer and Tumours' for further details
about cancer in general.

What is cancer of the oesophagus?

Cancer of the oesophagus is sometimes called oesophageal cancer. It is uncommon in the UK. However, in the
last 20 years or so the number of cases diagnosed each year has risen. There are two main types:

• Adenocarcinoma of the oesophagus. This occurs in about half of cases in the UK. This type arises from
cells within mucus glands. (The lining of the oesophagus contains many tiny glands which make mucus. The
mucus helps food to slide down into the stomach easily.) This type mainly occurs in the lower third of the
oesophagus.
• Squamous cell carcinoma of the oesophagus. This occurs in about half of cases in the UK. This type
arises from cells which are on the inside lining of the oesophagus. This type of mainly occurs in the upper two
thirds of the oesophagus.

The symptoms, treatment and outlook are similar for both of the these types. (There are some rare types of
cancer which arise from other cells in the oesophagus. These are not dealt with further in this leaflet.)

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 What causes cancer of the oesophagus?

A cancerous tumour starts from one abnormal cell. The exact reason why a cell becomes cancerous is unclear.
It is thought that something damages or alters certain genes in the cell. This makes the cell abnormal and
multiply 'out of control'. (See separate leaflet called 'What Causes Cancer' for more details.)

Many people develop cancer of the oesophagus for no apparent reason. However, certain 'risk factors' increase
the chance that cancer of the oesophagus may develop. These include:

• Ageing. It is more common in older people. Most cases are in people over the age of 50.
• Diet is probably a factor. A high fat diet is thought to increase the risk and eating a lot of fruit and green
vegetables is thought to reduce the risk. Obesity may increase the risk too.
• Where you live. Cancer of the oesophagus is much more common in China and certain other far eastern
countries than in Europe. This may be due to dietary factors, or some other environmental factor.
• Smoking.
• Drinking a lot of alcohol.
• Long-standing acid reflux from the stomach (gastro-oesophageal reflux disease or GORD). This
condition is common and causes inflammation at the lower end of the oesophagus. (See separate leaflet
called 'Acid Reflux and Oesophagitis'.) However, it has to be stressed that the risk is small - most people with
acid reflux do not develop cancer.
• Barrett's oesophagus. This is a condition at the lower end of the oesophagus where the cells which line
the oesophagus have become changed. In many cases this is related to long-term inflammation caused by
acid reflux. The changed cells have an increased risk of becoming cancerous. About 2 in 100 people with
Barrett's oesophagus develop cancer of the oesophagus at some stage.
• Other uncommon conditions are associated with an increased risk and include: achalasia (a condition
which causes a widening at the bottom of the oesophagus); tylosis (a rare inherited skin condition); and
Paterson-Brown Kelly syndrome (a rare syndrome which includes iron deficiency and changes in the mouth
or oesophagus).
• Long-term exposure to certain chemicals and pollutants (chemical carcinogens) may 'irritate' the
oesophagus if you breathe them in and may increase the risk.

What are the symptoms of cancer of the oesophagus?

When a cancer of the oesophagus first develops and is small it usually causes no symptoms. Some do not
cause symptoms until they are quite advanced. As the cancer grows the initial symptoms which may develop
usually include one or more of the following.

• Difficulty swallowing (dysphagia). This is often the first symptom and is caused by a tumour narrowing
the passage in the oesophagus. Food may appear to 'stick' as you try to swallow. If it gets worse then drinks
may also be difficult to swallow.
• Vomiting after eating (which is really regurgitating food which has become stuck).
• Pain in the chest or in the back of the chest when you swallow (odynophagia)..
• Weight loss.
• Vomiting blood.
• Coughing. Particularly when you swallow.
• A hoarse voice.
• Acid reflux symptoms may first develop, or get worse, when you develop a cancer at the lower
oesophagus next to the stomach. Symptoms include heartburn (pains in the chest). But, acid reflux is
common and most people with acid reflux do not have cancer.

If the cancer spreads to other parts of the body, various other symptoms can develop.

All the above symptoms can be due to other conditions, so tests are needed to confirm cancer of the
oesophagus.
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 How is cancer of the oesophagus diagnosed and assessed?

Initial assessment and gastroscopy

If a doctor suspects that you may have cancer of the oesophagus, he or she will examine you to look for signs
such as a lump in your abdomen, etc. The examination is often normal, especially if the cancer is at an early
stage. Therefore, a gastroscopy (endoscopy) is usually arranged.

A gastroscope (endoscope) is a thin, flexible, telescope. It is passed through the mouth, into the oesophagus
and down towards the stomach. The endoscope contains fibre optic channels which allows light to shine down
so the doctor can see inside. See separate leaflet for details about gastroscopy.

Biopsy - to confirm the diagnosis

A biopsy is when a small sample of tissue is removed from a part of the body. The sample is then examined
under the microscope to look for abnormal cells. When you have a gastroscopy, if anything abnormal is seen
then the doctor or nurse can take a biopsy. This is done by passing a thin grabbing instrument down a side
channel of the gastroscope.

Assessing the extent and spread

If you are confirmed to have cancer of the oesophagus, further tests may be done. For example, a special
ultrasound scan which uses a probe at the end of a gastroscope can assess how far the cancer has grown
through the wall of the oesophagus. A barium swallow is another type of test which can usually show a tumour
of the oesophagus quite clearly on an x-ray.

Other tests may be arranged to see if the cancer has spread to other parts of the body. For example, a CT scan,
an ultrasound scan of the liver, or other tests. (There are separate leaflets which describe each of these tests in
more detail.)

This assessment is called 'staging' of the cancer. The aim of staging is to find out:

• How much the tumour in the oesophagus has grown, and whether it has grown partially or fully through
the wall of the oesophagus.
• Whether the cancer has spread to local lymph nodes.
• Whether the cancer has spread to other areas of the body (metastasised).

By finding out the stage of the cancer it helps doctors to advise on the best treatment options. It also gives a
reasonable indication of outlook (prognosis).

See separate leaflet called 'Cancer Staging and Grading' for details.

What are the treatment options for cancer of the oesophagus?

Treatment options which may be considered include surgery, chemotherapy and radiotherapy. The treatment
advised for each case depends on various factors such as the exact site of the primary tumour in the
oesophagus, the stage of the cancer (how large the cancer is and whether it has spread), and your general
health.

You should have a full discussion with a specialist who knows your case. They will be able to give the pros and
cons, likely success rate, possible side-effects, and other details about the possible treatment options for your
type of cancer.

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 You should also discuss with your specialist the aims of treatment. For example:

• Treatment may aim to cure the cancer. Some cancers of the oesophagus can be cured, particularly if
they are treated in the early stages of the disease. (Doctors tend to use the word 'remission' rather than the
word 'cured'. Remission means there is no evidence of cancer following treatment. If you are 'in remission',
you may be cured. However, in some cases a cancer returns months or years later. This is why doctors are
sometimes reluctant to use the word cured.)
• Treatment may aim to control the cancer. If a cure is not realistic, with treatment it is often possible limit
the growth or spread of the cancer so that it progresses less rapidly. This may keep you free of symptoms for
some time.
• Treatment may aim to ease symptoms. If a cure is not possible, treatments may be used to reduce the
size of a cancer which may ease symptoms such as pain or difficulty swallowing. If a cancer is advanced then
you may require treatments such as nutritional supplements, painkillers, or other techniques to help keep you
free of pain or other symptoms.

Surgery
It may be possible to remove the tumour. To do this, the operation is to remove part or all of the oesophagus,
depending on the site and size of the tumour.

There are various ways a surgeon can get to the oesophagus, and various types of operation. If part of the
oesophagus is removed it may be possible to sew the stomach back onto the remaining section of oesophagus
if the stomach is brought up into the chest area. If all of the oesophagus is removed, the surgeon may use a
section of your intestine to create a new 'artificial' oesophagus. These procedures are major operations and
carry some risk.

Even if the cancer is advanced and it is not possible to remove it, some surgical techniques may still have a
place to ease symptoms. For example, a blockage may be eased by using laser surgery, or by inserting a rigid
stent (tube) which allows food and drink to pass through the blockage to the stomach.

Chemotherapy
Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells, or stops them from
multiplying. See separate leaflet called chemotherapy for more details.

Chemotherapy may be used in addition to surgery or radiotherapy. For example, following surgery you may be
given a course of chemotherapy. This aims to kill any cancer cells which may have spread away from the
primary tumour. When chemotherapy is used after surgery it is called adjuvant chemotherapy. In some cases
chemotherapy is given before surgery to shrink a large tumour so that surgery is more likely to be successful.
This is called neoadjuvant chemotherapy.

Radiotherapy
Radiotherapy is a treatment which uses high energy beams of radiation which are focussed on cancerous
tissue. This kills cancer cells, or stops cancer cells from multiplying. (There is a separate leaflet which gives
more details about radiotherapy.) When radiotherapy is used to treat cancer of the oesophagus it is commonly
used in addition to either surgery or chemotherapy. The exact combination of treatments advised depends on
various factors.

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What is the prognosis (outlook)?

Without treatment, a cancer of the oesophagus is likely get larger, and spread to other parts of the body. If it is
diagnosed and treated at an early stage (before growing through the wall of the oesophagus or spreading to
lymph nodes or other areas of the body) then there is a chance of a cure with treatment. Unfortunately, most
cases in the UK are not diagnosed at an early stage. This is because symptoms do not tend to develop until the
cancer is already fairly large.

If the cancer is diagnosed when it has grown through the wall of the oesophagus, or spread to other parts of the
body, a cure is less likely. However, treatment can often slow down the progression of the cancer.

The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the
information on outlook above is very general. The specialist who knows your case can give more accurate
information about your particular outlook, and how well your type and stage of cancer is likely to respond to
treatment.

OESOPHAGEAL CANCER: WHAT IS IT?

Oesophageal cancer (also called cancer of the oesophagus) is a malignant tumour that grows in the
lining of the oesophagus. The oesophagus (the gullet) is the tube that carries food from the mouth
down into the stomach using a series of muscular movements. Oesophageal cancer is far more
common in men than women, and usually affects people older than 50.

Types of oesophageal cancer

Two types of cancer, squamous cell carcinoma and adenocarcinoma, make up 90 per cent of all
oesophageal cancers. Oesophageal cancer can occur in any section of the oesophagus. Most cancers in
the top part of the oesophagus are squamous cell cancers. They are called this because the cells lining
the top part of the oesophagus are squamous cells. Squamous means scaly.

Most cancers at the end of the oesophagus that joins the stomach are adenocarcinomas.
Adenocarcinomas are often found in people who have a condition called Barrett’s oesophagus. In
Barrett’s oesophagus, long term gastro-oesophageal reflux damages the normal squamous cells that
line the oesophagus by repeatedly bathing them in acidic stomach contents. Over time the squamous
cells are replaced by cells more like the ones in the stomach and small intestine. It is in these new cells,
the so-called Barrett’s metaplasia, that adenocarcinomas can develop. Because some people with
Barrett’s oesophagus will go on to develop cancer of the oesophagus, regular screening may be
required to detect any pre-cancerous cells that may develop.

Who gets oesophageal cancer?

Oesophageal cancer is relatively uncommon in Australia but in some parts of Asia it is very common.
In many Western countries adenocarcinoma is becoming much more common.

What causes oesophageal cancer?

What causes this type of cancer is not fully understood, but it is thought that there are a number of risk
factors and conditions that, if present for any length of time, may lead to oesophageal cancer. These
include the following.

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 • Barrett’s oesophagus (a condition caused by repeated episodes of reflux that results in changes to the
usual cell lining of the oesophagus).
• Smoking.
• Drinking large quantities of alcohol on a regular basis.
• Regularly consuming very hot drinks or foods.
• Obesity.
• Vitamin and other nutritional deficiencies.
• Being exposed to certain chemicals, such as nitrosamines.
• Achalasia — a condition where the muscles of the lower oesophageal sphincter (the ‘valve’ that controls
food passing from the oesophagus to the stomach) can’t relax properly and so food builds up in the
oesophagus and doesn’t pass to the stomach. Also, the normal waves of muscle contractions that propel
food down the oesophagus don’t work properly, also adding to the build-up of food.
• Plummer-Vinson syndrome — a rare condition that causes anaemia, tongue abnormalities and oesophageal
webs (abnormal protrusions of tissue into the oesophagus that interfere with swallowing).

You should always check with your doctor if you have any difficulty swallowing or have constant
episodes of reflux, or if you develop any of the symptoms that may indicate oesophageal cancer, such
as:

• difficulty swallowing that worsens over time;

• pain on swallowing;
• unexplained weight loss;
• coughing after swallowing;
• chest or back pain; and
• a hoarse voice.

Early detection of this cancer is extremely important as it does improve the chance of successful
treatment. Unfortunately, this type of cancer, even if successfully treated, can often recur even after
surgery, chemotherapy and/or radiation treatment.

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