An Overview of Esophageal Cancer

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Esophageal cancer is uncommon, but is one of the top 10 causes of cancer-related deaths in the United States, since it is often diagnosed at a stage when it is no longer curable. In the past, squamous cell carcinoma of the esophagus—associated with smoking plus excessive alcohol use—was the most common type. But in recent years, it has been surpassed by adenocarcinoma, often associated with long-term acid reflux and obesity. Difficulty with swallowing is often the first symptom of esophageal cancer, and tests such as endoscopy help confirm a diagnosis. When caught early, surgery may cure the disease, but far too often the disease is advanced, and chemotherapy and radiation therapy become the mainstays of treatment.

Esophageal cancer varies tremendously around the globe, both in incidence and in the common risk factors. At the current time, esophageal adenocarcinoma is increasing in the United States and other developed countries, though the exact reasons are uncertain.

Understanding the Esophagus

The esophagus is the muscular tube that connects the mouth to the stomach. It lies behind the breastbone and trachea (the tube through which air passes on its way to the lungs), and in front of the thoracic spine. The area in the middle of the chest through which the esophagus passes is referred to as the mediastinum, a space that contains other structures such as the heart, large blood vessels (the aorta), and many lymph nodes.

Within the esophagus, there are a few important structures that control how solids and liquids pass from your mouth to your stomach during swallowing. The upper esophageal sphincter is a muscular band near the top of the esophagus that prevents backflow of food from the esophagus to the mouth, and also helps prevent aspiration (breathing food into the trachea). The lower esophageal sphincter is a band of tissue near the junction of the esophagus with the stomach. When the tone of this sphincter is either high or low (due to medical conditions or medications), it can affect how food passes from the esophagus into the stomach. Before reaching the stomach, the esophagus passes through the diaphragm. If this area of the diaphragm is weakened (a hiatal hernia), the stomach can move upward into the chest cavity.

Most of the length of the esophagus is lined with cells known as squamous cells, the same kind of cells found in the mouth, large airways, and even the skin. If a tumor begins in this region it is known as a squamous cell carcinoma. The area at the bottom of the esophagus, and where the esophagus joins the stomach, are lined with columnar cells. If a malignant tumor begins in this region, it's called an adenocarcinoma.

Squamous cell carcinomas were once more common in the United States, and remain the most common type of esophageal cancer worldwide. At the current time, adenocarcinomas are more common in the United States and several other developed countries.

Symptoms

Symptoms of esophageal cancer often become obvious only when the cancer is fairly advanced. That said, in retrospect, many people find that they have been having symptoms for some time, but have been unconsciously adapting to these signs (by eating softer foods, for example).

Potential warning signs include:

Since some of these symptoms may occur with acid reflux, and since acid reflux is a risk factor for esophageal cancer, it's important for people to be aware not only of new symptoms they experience but of any change in their chronic symptoms.

Signs and Symptoms of Esophageal Cancer

Causes and Risk Factors

We don't know the precise causes, though genetics seem to play a role. Several risk factors for esophageal cancer have been identified and they vary depending on the particular type of esophageal cancer.

Squamous cell carcinoma of the esophagus is often associated with a combination of smoking and excess alcohol intake, though there are other risk factors as well. Globally, esophageal cancer is more common in men than in women, but squamous cell carcinoma is more common in women in the United States. It is also more common in blacks than in whites. A diet rich in fruits and vegetables and low in red and processed meats may have a protective effect.

Adenocarcinoma of the esophagus is often associated with chronic acid reflux (gastroesophageal reflux disease, or GERD), as well as Barrett's esophagus and obesity. In the United States, it is more common in men than in women, and more common in whites than in blacks.

Causes and Risk Factors for Esophageal Cancer

Diagnosis

A number of different tests may be used to diagnose esophageal cancer. Often times, the first test ordered is a barium swallow. If esophageal cancer is suspected, however, an upper endoscopy (esophago-gastric-duodenoscopy) is the primary test used for making the diagnosis. In this procedure, a tube is placed through the mouth and into the esophagus. A camera at the end of the tube allows doctors to directly visualize the inside of the esophagus and take a biopsy if needed.

Staging is very important in choosing the best treatments for the disease. Tests commonly used for staging include CT, PET, and sometimes additional studies such as bronchoscopy, thoracoscopy, and others.

How Esophageal Cancer Is Diagnosed

Treatment

The treatment options for esophageal cancer will depend on the stage of cancer, where it is located, and a number of other factors.

For early-stage tumors, surgery (esophagectomy) may offer the chance for a cure. That said, it is major surgery that involves removing a portion of the esophagus and reconnecting the stomach to what remains of the upper esophagus (or adding a section of the intestine when a large portion of the esophagus is removed). Chemotherapy and radiation therapy are often done prior to surgery (neoadjuvant chemotherapy) to shrink a tumor, but may also be used after surgery to make sure any remaining cancer cells are treated.

For those who are not candidates for surgery, there are still options. Chemotherapy with a combination of drugs may prolong life. Radiation therapy is frequently used along with chemotherapy, either before surgery, after surgery, or along with chemotherapy when surgery is not possible.

Targeted therapies may also help control the disease, for example, in people who have tumors that are positive for HER2 (similar to breast cancer). Immunotherapy includes a variety of treatments that involve harnessing the body's own immune system to fight cancer, and can sometimes control even advanced cancers. There are also many treatments being studied in clinical trials that offer hope that better treatments will be available in the future.

For those with advanced cancers, treatments to improve quality of life while living with cancer can't be understated, and palliative care is often the goal of therapy. Palliative care is not the same as hospice (it can be used even for people with tumors that are very likely to be cured), and it aims to control the physical and emotional symptoms of living with cancer. We are learning that palliative care not only improves quality of life but may improve survival for people with advanced cancers.

How Esophageal Cancer Is Treated

Coping

Coping with esophageal cancer can be very difficult. Physically, difficulty with swallowing is not only uncomfortable but can interfere significantly with nutrition. Emotionally, the reputation of esophageal cancer as being an aggressive tumor with a poor prognosis raises many issues, including end-of-life concerns. Socially, a diagnosis of esophageal cancer often leads to unwelcome changes in roles within a family. And practical matters ranging from insurance concerns to finances add to the burden.

Coping with a diagnosis of esophageal cancer takes a village, and it's important to gather your support system close. Finding support among the esophageal cancer community online can also be of great benefit, as it brings the opportunity to talk with other people and their family caregivers who are facing a similar challenge.

Taking an active part in your treatment by being your own advocate in your cancer care may not only reduce some of the anxiety over the unknown but in some cases can make a difference in outcome as well.

Coping When You Have Esophageal Cancer

A Word From Verywell

Esophageal cancer often eludes diagnosis until it is in the later stages of the disease, yet many people admit to having symptoms long before they are diagnosed. Having an awareness of the signs and symptoms and knowing whether or not you have risk factors may be helpful in finding the disease as early as possible. It's important to note, however, that even if the disease isn't caught early and surgery is not possible, there are still treatments available that can reduce symptoms and often extend life.

What Are the Signs and Symptoms of Esophageal Cancer?
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