Keeping on Top of Your Condition
The Esophagus
The esophagus is a hollow tube that carries food and liquids from the
throat to the stomach. When a person swallows, the muscular walls of the
esophagus contract to push food down into the stomach. Glands in the
lining of the esophagus produce mucus, which keeps the passageway moist
and makes swallowing easier. The esophagus is located just behind the
trachea
(windpipe). In an adult, the esophagus is about 10 inches long.
Understanding the Cancer Process
Cancer
is a disease that affects cells, the body's basic unit of life. To
understand any type of cancer, it is helpful to know about normal cells
and what happens when they become cancerous.
The body is made up of many types of cells. Normally, cells grow,
divide, and produce more cells when they are needed. This process keeps
the body healthy and functioning properly. Sometimes, however, cells keep
dividing when new cells are not needed. The mass of extra cells forms a
growth or
tumor.
Tumors can be
benign
or
malignant.
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Benign tumors are not cancer. They usually can be removed and,
in most cases, they do not come back. Cells in benign tumors do not
spread to other parts of the body. Most important, benign tumors are
rarely a threat to life.
-
Malignant tumors are cancer. Cells in malignant tumors are
abnormal and divide without control or order. These cancer cells can
invade and destroy the tissue around them. Cancer cells can also break
away from a malignant tumor and enter the bloodstream or
lymphatic
system (the tissues and organs that produce, store, and carry
white blood cells that fight infection and other diseases). This
process, called
metastasis,
is how cancer spreads from the original (primary) tumor to form new
(secondary) tumors in other parts of the body.
Cancer that begins in the esophagus (also called
esophageal
cancer) is divided into two major types,
squamous
cell carcinoma and
adenocarcinoma,
depending on the type of cells that are malignant. Squamous cell
carcinomas arise in squamous cells that line the esophagus. These
cancers usually occur in the upper and middle part of the esophagus.
Adenocarcinomas usually develop in the glandular tissue in the
lower part of the esophagus. The treatment is similar for both types of
esophageal cancer.
If the cancer spreads outside the esophagus, it often goes to the
lymph
nodes first. (Lymph nodes are small, bean-shaped structures that
are part of the body's immune system.) Esophageal cancer can also spread
to almost any other part of the body, including the liver, lungs, brain,
and bones.
Esophagus Cancer Risk Factors
The exact causes of cancer of the esophagus are not known. However,
studies show that any of the following factors can increase the risk of
developing esophageal cancer:
-
Age. Esophageal cancer is more likely to occur as people get
older; most people who develop esophageal cancer are over age 60.
-
Sex. Cancer of the esophagus is more common in men than in
women.
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Tobacco Use. Smoking cigarettes or using smokeless tobacco is
one of the major risk factors for esophageal cancer.
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Alcohol Use. Chronic and/or heavy use of alcohol is another
major risk factor for esophageal cancer. People who use both alcohol and
tobacco have an especially high risk of esophageal cancer. Scientists
believe that these substances increase each other's harmful effects.
-
Barrett's Esophagus. Long-term irritation can increase the
risk of esophageal cancer. Tissues at the bottom of the esophagus can
become irritated if stomach acid frequently "backs up" into the
esophagus -- a problem called gastric
reflux.
Over time, cells in the irritated part of the esophagus may change and
begin to resemble the cells that line the stomach. This condition, known
as
Barrett's
esophagus, is a premalignant condition that may develop into
adenocarcinoma of the esophagus.
-
Other Types of Irritation. Other causes of significant
irritation or damage to the lining of the esophagus, such as swallowing
lye or other caustic substances, can increase the risk of developing
esophageal cancer.
-
Medical History. Patients who have had other head and neck
cancers have an increased chance of developing a second cancer in the
head and neck area, including esophageal cancer.
Having any of these risk factors increases the likelihood that a person
will develop esophageal cancer. Still, most people with one or even
several of these factors do not get the disease. And most people who do
get esophageal cancer have none of the known risk factors.
Identifying factors that increase a person's chances of developing
esophageal cancer is the first step toward preventing the disease. We
already know that the best ways to prevent this type of cancer are to quit
(or never start) smoking cigarettes or using smokeless tobacco and to
drink alcohol only in moderation. Researchers continue to study the causes
of esophageal cancer and to search for other ways to prevent it. For
example, they are exploring the possibility that increasing one's intake
of fruits and vegetables, especially raw ones, may reduce the risk of this
disease.
Researchers are also studying ways to reduce the risk of esophageal
cancer for people with Barrett's esophagus.
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The best ways to prevent cancer of the esophagus are to
quit (or never start) using tobacco and to limit the use of alcohol.
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Recognizing Symptoms of Esophageal Cancer
Early esophageal cancer usually does not cause symptoms. However, as
the it grows, symptoms of esophageal cancer may include:
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Difficult or painful swallowing
-
Severe weight loss
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Pain in the throat or back, behind the breastbone or between the
shoulder blades
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Hoarseness or chronic cough
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Vomiting
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Coughing up blood
These symptoms may be caused by esophageal cancer or by other
conditions. It is important to check with a doctor.
Diagnosing Esophageal Cancer
To help find the cause of symptoms, the doctor evaluates a person's
medical history and performs a physical exam. The doctor usually orders a
chest
x-ray
and other diagnostic tests. These tests may include the following:
-
A barium swallow (also called an
esophagram)
is a series of x-rays of the esophagus. The patient drinks a liquid
containing barium, which coats the inside of the esophagus. The barium
makes any changes in the shape of the esophagus show up on the x-rays.
-
Esophagoscopy (also called
endoscopy)
is an examination of the inside of the esophagus using a thin lighted
tube called an
endoscope.
An anesthetic (substance that causes loss of feeling or awareness) is
usually used during this procedure. If an abnormal area is found, the
doctor can collect cells and tissue through the endoscope for
examination under a microscope. This is called a
biopsy.
A biopsy can show cancer, tissue changes that may lead to cancer, or
other conditions.
Staging the Disease
If the diagnosis is esophageal cancer, the doctor needs to learn the
stage (or extent) of disease.
Staging
is a careful attempt to find out whether the cancer has spread and, if so,
to what parts of the body. Knowing the stage of the disease helps the
doctor plan treatment. Listed below are descriptions of the four stages of
esophageal cancer.
-
Stage I. The cancer is found only in the top layers of cells
lining the esophagus.
-
Stage II. The cancer involves deeper layers of the lining of
the esophagus, or it has spread to nearby lymph nodes. The cancer has
not spread to other parts of the body.
-
Stage III. The cancer has invaded more deeply into the wall of
the esophagus or has spread to tissues or lymph nodes near the
esophagus. It has not spread to other parts of the body.
-
Stage IV. The cancer has spread to other parts of the body.
Esophageal cancer can spread almost anywhere in the body, including the
liver, lungs, brain, and bones.
Some tests used to determine whether the cancer has spread include:
-
CAT
(or CT) scan (computed tomography). A computer linked to an
x-ray machine creates a series of detailed pictures of areas inside the
body.
-
Bone scan. This technique, which creates images of bones on a
computer screen or on film, can show whether cancer has spread to the
bones. A small amount of radioactive substance is injected into a vein;
it travels through the bloodstream, and collects in the bones,
especially in areas of abnormal bone growth. An instrument called a
scanner measures the radioactivity levels in these areas.
-
Bronchoscopy. The doctor puts a
bronchoscope
(a thin, lighted tube) into the mouth or nose and down through the
windpipe to look into the breathing passages.
Esophageal Cancer Treatment
Treatment for esophageal cancer depends on a number of factors,
including the size, location, and extent of the tumor, and the general
health of the patient. Patients are often treated by a team of
specialists, which may include a
gastroenterologist
(a doctor who specializes in diagnosing and treating disorders of the
digestive system), surgeon (a doctor who specializes in removing or
repairing parts of the body),
medical
oncologist (a doctor who specializes in treating cancer), and
radiation
oncologist (a doctor who specializes in using radiation to treat
cancer). Because cancer treatment may make the mouth sensitive and at risk
for infection, doctors often advise patients with esophageal cancer to see
a dentist for a dental exam and treatment before cancer treatment begins.
Many different treatments and combinations of treatments may be used to
control the cancer and/or to improve the patient's quality of life by
reducing esophageal cancer symptoms.
-
Surgery
is the most common treatment for esophageal cancer. Usually, the surgeon
removes the tumor along with all or a portion of the esophagus, nearby
lymph nodes, and other tissue in the area. (An operation to remove the
esophagus is called an esophagectomy.) The surgeon connects the
remaining healthy part of the esophagus to the stomach so the patient is
still able to swallow. Sometimes, a plastic tube or part of the
intestine is used to make the connection. The surgeon may also widen the
opening between the stomach and the small intestine to allow stomach
contents to pass more easily into the small intestine. Sometimes surgery
is done after other treatment is finished.
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Radiation
therapy, also called radiotherapy, involves the use of
high-energy rays to kill cancer cells. Radiation therapy affects cancer
cells in the treated area only. The radiation may come from a machine
outside the body (external radiation) or from radioactive materials
placed in or near the tumor (internal radiation). A plastic tube may be
inserted into the esophagus to keep it open during radiation therapy.
This procedure is called intraluminal intubation and dilation. Radiation
therapy may be used alone or combined with chemotherapy as primary
treatment instead of surgery, especially if the size or location of the
tumor would make an operation difficult. Doctors may also combine
radiation therapy with chemotherapy to shrink the tumor before surgery.
Even if the tumor cannot be removed by surgery or destroyed entirely by
radiation therapy, radiation therapy can often help relieve pain and
make swallowing easier.
-
Chemotherapy
is the use of anticancer drugs to kill cancer cells. The anticancer
drugs used to treat esophageal cancer travel throughout the body.
Anticancer drugs used to treat esophageal cancer are usually given by
injection into a vein (IV). Chemotherapy may be combined with radiation
therapy as primary treatment (instead of surgery) or to shrink the tumor
before surgery.
-
Laser
therapy is the use of high-intensity light to destroy tumor
cells. Laser therapy affects the cells only in the treated area. The
doctor may use laser therapy to destroy cancerous tissue and relieve a
blockage in the esophagus when the cancer cannot be removed by surgery.
The relief of a blockage can help to reduce symptoms of esophageal cancer,
especially swallowing problems.
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Photodynamic
therapy (PDT), a type of laser therapy, involves the use of
drugs that are absorbed by cancer cells; when exposed to a special
light, the drugs become active and destroy the cancer cells. The doctor
may use PDT to relieve symptoms of esophageal cancer such as difficulty
swallowing.
Clinical
trials (research studies) to evaluate new ways to treat cancer are
an important option for many patients with esophageal cancer. In some
studies, all patients receive the new treatment. In others, doctors
compare different therapies by giving the new treatment to one group of
patients and the usual (standard) therapy to another group. Through
research, doctors learn new, more effective ways to treat cancer. More
information about research studies can be found in the NCI publication
3. NCI's Web site has a section on
clinical trials at
This section provides general information about clinical trials and
detailed information about specific ongoing studies. This information is
also available from the Cancer Information Service at 1-800-4-CANCER
(1-800-422-6237). For deaf and hard of hearing callers with TTY equipment,
the number is 1-800-332-8615.
Side Effects of Treatment
The
side
effects of cancer treatment depend on the type of treatment and
may be different for each person. Doctors and nurses can explain the
possible side effects of treatment, and they can suggest ways to help
relieve symptoms that may occur during and after treatment.
-
Surgery for esophageal cancer may cause short-term pain and
tenderness in the area of the operation, but this discomfort or pain can
be controlled with medicine. Patients are taught special breathing and
coughing exercises to keep their lungs clear.
-
Radiation therapy affects normal as well as cancerous cells.
Side effects of radiation therapy depend mainly on the dose and the part
of the body that is treated. Common side effects of radiation therapy to
the esophagus are a dry, sore mouth and throat; difficulty swallowing;
swelling of the mouth and gums; dental cavities; fatigue; skin changes
at the site of treatment; and loss of appetite.
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Chemotherapy, like radiation therapy, affects normal as well
as cancerous cells. Side effects depend largely on the specific drugs
and the dose (amount of drug administered). Common side effects of
chemotherapy include nausea and vomiting, poor appetite, hair loss, skin
rash and itching, mouth and lip sores, diarrhea, and fatigue. These side
effects generally go away gradually during the recovery periods between
treatments or after treatment is over.
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Laser therapy can cause short-term pain where the treatment
was given, but this discomfort can be controlled with medicine.
-
Photodynamic therapy makes the skin and eyes highly sensitive
to light for 6 weeks or more after treatment. Other temporary side
effects of PDT may include coughing, trouble swallowing, abdominal pain,
and painful breathing or shortness of breath.
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Doctors and nurses can explain the possible side effects
of treatment, and they can suggest ways to help relieve symptoms
that may occur during and after treatment.
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Nutrition for Cancer Patients
Eating well during cancer treatment means getting enough calories and
protein to control weight loss and maintain strength. Eating well often
helps people with cancer feel better and have more energy.
However, many people with esophageal cancer find it hard to eat well
because they have difficulty swallowing. Patients may not feel like eating
if they are uncomfortable or tired. Also, the common side effects of
treatment, such as poor appetite, nausea, vomiting, dry mouth, or mouth
sores, can make eating difficult. Foods may taste different.
After surgery, patients may receive nutrients directly into a vein.
(This way of getting nourishment into the body is called an
IV.)
Some may need a feeding tube (a flexible plastic tube that is passed
through the nose to the stomach or through the mouth to the stomach) until
they are able to eat on their own.
Patients with esophageal cancer are usually encouraged to eat several
small meals and snacks throughout the day, rather than try to eat three
large meals. When swallowing is difficult, many patients can still manage
soft, bland foods moistened with sauces or gravies. Puddings, ice cream,
and soups are nourishing and are usually easy to swallow. It may be
helpful to use a blender to process solid foods. The doctor, dietitian,
nutritionist, or other health care provider can advise patients about
these and other ways to maintain a healthy diet.
The Importance of Followup Care
Followup care after treatment for esophageal cancer is important to
ensure that any changes in health are found. If the cancer returns or
progresses or if a new cancer develops, it can be treated as soon as
possible. Checkups may include physical exams, x-rays, or lab tests.
Between scheduled appointments, patients should report any health problems
to their doctor as soon as they appear.
Providing Emotional Support
Living with a serious disease is challenging. Apart from having to cope
with the physical and medical challenges, people with cancer face many
worries, feelings, and concerns that can make life difficult. They may
find they need help coping with the emotional as well as the practical
aspects of their disease. In fact, attention to the emotional burden of
having cancer is often a part of a patient's treatment plan. The support
of the health care team (doctors, nurses, social workers), support groups,
and patient-to-patient networks can help people feel less isolated and
distressed, and improve the quality of their lives. Cancer support groups
provide a setting in which cancer patients can talk about living with
cancer with others who may be having similar experiences. Patients may
want to speak to a member of their health care team about finding a
support group.
Questions for Your Doctor
This booklet is designed to help you get information you need from your
doctor so that you can make informed decisions about your health care. In
addition, asking your doctor the following questions will help you further
understand your condition. To help you remember what the doctor says, you
may take notes or ask whether you may use a tape recorder. Some people
also want to have a family member or friend with them when they talk to
the doctor -- to take part in the discussion, to take notes, or just to
listen.
Diagnosis
Treatment
-
What treatments are recommended for me?
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What clinical trials are appropriate for my type of cancer?
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Will I need to be in the hospital to receive my treatment? For how
long?
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How might my normal activities change during my
treatment?
Side Effects
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What side effects should I expect? How long will they last?
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Whom should I call if I am concerned about a side effect?
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What will be done if I have pain?
Followup
-
After treatment, how often do I need to be checked? What type of
followup care should I have?
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What type of nutritional support will I need? Where can I get it?
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Will I eventually be able to resume my normal activities?
The Health Care Team
-
Who will be involved with my treatment and rehabilitation? What is
the role of each member of the health care team in my care?
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What has been your experience in caring for patients with esophageal
cancer?
Resources
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Are there support groups in the area with people I can talk to?
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Are there organizations where I can get more information about
cancer, specifically esophageal cancer?
Keeping on Top of Your Condition
Keeping in tune with your disease or condition not only makes treatment less intimidating but also increases its chance of success, and has been shown to lower a patients risk of complications. As well, as an informed patient, you are better able to discuss your condition and treatment options with your physician.
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