Oesophageal cancer

About the oesophagus

The oesophagus (the food pipe) is a muscular tube that connects the throat to the stomach. In adults, it is about 25 cm long and lies behind the windpipe, which is used for breathing.

The oesophagus is part of the upper gastrointestinal (GI) tract, which is a section of the digestive system. It takes food and liquids (including saliva) from the mouth to the stomach. A valve (sphincter) at the lower end of the oesophagus stops acid and food moving from the stomach back into the oesophagus.

What is oesophageal cancer?

Oesophageal cancer begins when abnormal cells develop in the innermost layer of the oesophagus, called the mucosa.

A tumour can start anywhere along the oesophagus. There are two main types:

• Oesophageal adenocarcinoma – This type often starts near the gastro-oesophageal junction and is linked with Barretts oesophagus. Adenocarcinomas are the most common form of oesophageal cancer in Australia.
• Oesophageal squamous cell carcinoma – This type starts in the thin, flat cells of the mucosa, which are called squamous cells. It often begins in the middle and upper part of the oesophagus.

Another type is gastro-oesophageal junction cancer. This starts where the oesophagus meets the stomach. It is usually treated like oesophageal cancer, but sometimes like stomach cancer.

If not found and treated early, oesophageal cancer can spread to nearby lymph nodes or to other parts of the body (e.g. liver and lungs). It can also grow through the oesophageal wall and into nearby organs.

How common is oesophageal cancer?

In Australia, about 1785 people are diagnosed with oesophageal cancer each year. Men are almost 3 times more likely than women to be diagnosed with this cancer. It is more common in people over 60, but it can occur at any age.

What are the symptoms?

Oesophageal cancer may not cause any symptoms in the early stages. If there are symptoms, these can include:

• difficulty swallowing
• heartburn or reflux that is new
• reflux that doesn’t go away
• food or fluids “catching” in the throat, or episodes of bringing food back up (regurgitation)
• pain when swallowing
• unexplained weight loss or loss of appetite
• feeling uncomfortable in the upper abdomen, especially when eating
• unexplained tiredness that won’t go away
• vomit that has blood in it
• black or bloody stools (poo).

Not everyone with these symptoms has oesophageal cancer. If you have symptoms that do not improve, see your general practitioner (GP).

What are the risk factors?

The exact causes of oesophageal cancer are not known. However, certain factors can increase the risk.

Many people with these risk factors do not develop oesophageal cancer. The risk factors are different for oesophageal adenocarcinoma and oesophageal squamous cell carcinoma.

For oesophageal adenocarcinoma:

• being overweight or obese
• medical conditions, including gastro-oesophageal reflux disease (GORD) and Barretts oesophagus
• smoking tobacco
• being over 60.

For oesophageal squamous cell carcinoma:

• drinking alcohol
• smoking tobacco
• being over 60
• damage to the oesophagus from swallowing very hot liquids or corrosive substances (e.g. acid).

Diagnosis

If your GP suspects oesophageal cancer, they will examine you, arrange initial tests and refer you to a specialist, such as a gastroenterologist. These are some of the tests you may have:

• Endoscopy and biopsy – The main tests are endoscopy and biopsy, which are often done at the same time. An endoscopy (also called a gastroscopy or upper endoscopy) lets your doctor look inside your oesophagus and stomach. A long, flexible tube with a light and small camera on the end (endoscope) will be passed into your mouth, down your throat and oesophagus, and into your stomach and small bowel. If the doctor sees anything unusual during the endoscopy, they may take a small sample of tissue. This is called a biopsy.

If a biopsy shows you have oesophageal cancer, you may have more tests to see if the cancer has spread. Some tests may be repeated during or after treatment to check your health and how well treatment is working.

• Blood tests – a sample of your blood is checked. Checks your general health, checks for low red blood cell count (anaemia), and sees how your liver and kidneys are working.
• Imaging scans – pictures of the inside of your body using CT, MRI or PET–CT scans, to check if the cancer has spread to other parts of your body.
• Laparoscopy – keyhole surgery using a thin tube with a camera, to check if cancer has spread to the stomach’s outer layer or the lining of the abdomen.
• Genomic testing – special tests on tissue removed during surgery. Finds gene changes (mutations) in cancer cells, which helps decide which treatments may work best.
• Endoscopic ultrasound (EUS) – an EUS is often done at the same time as a standard endoscopy. Sometimes it is done shortly after if more information is needed or to help with staging. The doctor uses an endoscope with an ultrasound probe on the tip or with a built-in ultrasound device. If you have cancer, this test can help to show whether the cancer has spread into the oesophageal or stomach wall, nearby tissues or lymph nodes.

Oesophageal cancer stages

Working out how far the cancer has spread is called staging. It helps your doctors recommend the best treatment for you.

The TNM staging system is the method most often used to stage oesophageal cancers. TNM stands for “tumour, node, metastasis”. The specialist gives numbers to the size of the tumour (T1–4), whether or not lymph nodes are affected (N0–N3), and whether the cancer has spread or metastasised (M0 or M1). Lower numbers mean the cancer is less advanced.

The TNM scores are combined to work out the overall stage of the cancer, from stage 1 to stage 4. Ask your doctor to explain what the stage of the cancer means for you. You can also call Cancer Council 13 11 20.

The stages of oesophageal cancer are:

• Stage 1 – early or limited cancer; tumour is found only in the oesophageal wall lining
• Stages 2-3 – locally advanced cancer; tumour has spread deeper into the layers of the oesophageal wall and to nearby lymph nodes
• Stage 4 – metastatic or advanced cancer; tumour has spread beyond the oesophageal wall to nearby lymph nodes or parts of the body, or to distant lymph nodes and parts of the body

Treatment

The most important factors in planning treatment for oesophageal cancer are the type of cancer and the stage of the disease. Treatment will also depend on your age, medical history and general health.

Treatment options for oesophageal cancer include:

• surgery alone
• chemotherapy before and after surgery
• combined chemotherapy and radiation therapy before surgery
• combined chemotherapy and radiation therapy without surgery
• radiation therapy alone
• clinical trial (ask your doctor for more information).

When chemotherapy and radiation therapy are combined, this is called chemoradiation. You will usually have both treatments on the same day.

Surgery

Surgery is often recommended if oesophageal cancer has not spread to other parts of the body. The aim is to remove all of the cancer while keeping as much healthy tissue as possible. The surgeon will also remove some healthy tissue around the cancer (a margin) to reduce the risk of the cancer coming back in the future.

The procedure can be done as open surgery, keyhole surgery or robotic surgery. Your surgeon will talk to you about the best type of surgery for you.

Depending on where the tumour is growing and how advanced the cancer is, you may have an endoscopic resection or an oesophagectomy:

• Oesophagectomy (surgical resection) – Surgery to remove part or all of the oesophagus plus nearby affected lymph nodes. Many people have chemotherapy before and after surgery, as this approach has been shown to have better long-term results.
• Endoscopic resection – A way for doctors to remove tissue from the oesophagus without needing more major surgery. A thin tube is passed through the mouth and into the oesophagus. An endoscopic resection helps with diagnosis and staging. For some people with early-stage oesophageal cancer, it may also treat the cancer by removing the whole tumour.

Oesophageal cancer surgery is complex. Surgeons who regularly perform this type of surgery have better outcomes.

If you live far from a specialist centre, you would have to travel to have surgery. You may be eligible for help with travel costs. For more information, call Cancer Council 13 11 20.

Chemotherapy

Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells, while causing the least possible damage to healthy cells.

Chemotherapy for oesophageal cancer may be given alone, or it may be combined with radiation therapy (chemoradiation). It may be used:

• before surgery (neoadjuvant chemotherapy) – to shrink a large tumour and destroy any cancer cells that may have spread
• after surgery (adjuvant chemotherapy) – to reduce the chance of the cancer coming back
• combined with radiation therapy – this is called chemoradiation
• on its own (palliative treatment) – for people who cannot have surgery or when cancer has spread to other parts of the body. Also to help control the cancer and improve quality of life.

For people having surgery, chemotherapy is now commonly recommended before and after surgery.

Radiation therapy

Also known as radiotherapy, this is the main treatment for oesophageal cancer that cannot be removed by surgery and has not spread to other parts of the body. Radiation in low doses is also often used to shrink cancer that has spread to other parts of the body.

Radiation therapy uses a controlled dose of radiation, such as focused x-ray beams, to kill or damage cancer cells. The radiation is targeted at the cancer, and treatment is carefully planned to do as little harm as possible to healthy body tissue near the cancer.

Radiation therapy may be given alone or combined with chemotherapy (chemoradiation). Chemoradiation is sometimes the only treatment needed or it may be used before surgery.

Immunotherapy

Immunotherapy uses the body’s own immune system to fight cancer. It is sometimes used after surgery or to treat people with advanced oesophageal cancer. This type of cancer treatment is changing rapidly. Talk to your doctor about whether immunotherapy is an option for you.

Side effects of cancer treatments

All cancer treatments can have side effects. Your treatment team will discuss these with you before you start treatment. Talk to your doctor or nurse about any side effects you are experiencing.

Some side effects can be upsetting and difficult, but there is help if you need it. Call Cancer Council Victoria Tel. 13 11 20 or contact cancer support to speak with a caring cancer nurse for support.

Having a stent

People with advanced oesophageal cancer who have trouble swallowing and do not have any other treatment options may have a flexible tube (called a stent) inserted into the oesophagus during an endoscopy.

The stent expands the oesophagus so that fluid and soft food can pass into the stomach more easily. It also can prevent food and saliva going into the lungs and causing infection.

The stent does not treat the cancer but will allow you to eat and drink more normally, although there may be some foods you are no longer able to eat.

Palliative treatment

Palliative treatment helps improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease. It is best thought of as supportive care.

Many people think palliative care is only for people at the end of life, but it can help at any stage of advanced oesophageal cancer. Treatments will be tailored to your individual needs. For example, radiation therapy can relieve pain and make swallowing easier by helping to shrink a tumour that is blocking the oesophagus.

Follow-up appointments

You will have regular appointments to monitor your health, manage any long-term side effects and check whether the cancer has come back or spread.

During check-ups, you may have blood tests, imaging scans or an endoscopy if necessary. You will also be able to discuss how you are feeling and any concerns you have.

How often you see your doctor will depend on the level of monitoring needed for the type and stage of the cancer you had. You may also see a dietitian for advice about nutrition.

For some people, oesophageal cancer does come back. If this happens, you may have further treatment, including chemotherapy, radiation therapy or surgery.

Support for carers, family and friends of someone with stomach cancer

Caring for someone with cancer can be difficult sometimes. If you are caring for someone with stomach cancer, these organisations can help:

• Cancer Council Victoria Tel. 13 11 20
• Carer Gateway Tel. 1800 422 737
• Carers Australia Tel. 1800 242 636

Where to get help

• Your GP (doctor)
• Your treatment team
• Cancer Council Victoria Tel. 13 11 20
  • Information and support line Tel. 13 11 20 (or Tel. 13 14 50 for an interpreter)
  • Oesophageal cancer
  • Cancer Council Victoria, My Cancer Guide - Find support services that are right for you.
• WeCan website – helps people affected by cancer find the information, resources and support services they may need following a diagnosis of cancer