The esophagus is the muscular tube of swallowing that connects the throat to the stomach. It passes through the neck and chest until it meets the stomach in the abdomen. Like all cancers, esophageal cancer develops as a result of uncontrolled cell division leading to uninterrupted growth. Cancerous cells begin their growth microscopically, but as they continue to multiply, turn into masses called tumors. These tumors may remain local in the tissue in which they originated or in more advanced cases, invade into surrounding structures or spread throughout the body, known as metastasizing. A cell with the ability to invade or spread is considered malignant or “cancerous”.
Esophageal cancer starts in the inner layer of the esophagus (mucosa) and then grows outward. As the tumor grows, patients develop difficulty swallowing (dysphagia) and eventually chest pain. Men are three times more likely to develop esophageal cancer than women and chronic acid exposure (gastoesophageal reflux disease) is believed to increase risk for its development. While gastroesophageal reflux disease (GERD) is common, most patients with GERD do not develop esophageal cancer. Heavy alcohol and tobacco use is believed to increase the risk for developing esophageal cancer.
There were 18,170 new esophageal cancers diagnosed in the United States in 2014 with 15,450 deaths reported. Esophageal cancer makes up 1% of the cancers diagnosed in the United States. Treatment and survival continue to improve and while overall survival for esophageal cancer is poor, prognosis for early stage cancer is considerably higher.
Esophageal cancer in its early stages has no symptoms and is usually picked up accidentally when evaluating for other problems. As the tumor grows, the most common symptom is difficulty swallowing (dysphagia) with food sticking in the throat or chest. This symptom worsens as the tumor grows and esophagus narrows. If not diagnosed and treated, swallowing becomes more difficult and progresses to the point where a patient is only able to swallow liquids. With decreased caloric intake, a patient loses weight.
Swallowing symptoms typically lead to further testing. The first test obtained is typically a barium swallow. Barium is a chalky liquid and when swallowed, outlines the esophagus on x-rays. If an x-ray shows narrowing or irregularity, the concern is raised for esophageal cancer.
Endoscopy is performed on an outpatient basis. A patient is sedated and a flexible telescope (endoscope) is inserted into the mouth, through the esophagus and directed into the stomach. Esophageal cancer is visible as a growth (tumor) from the wall of the esophagus during endoscopy and samples (biopsies) of the tumor are taken using specially designed instruments inserted through the endoscope. These biopsies are looked at under the microscope by a pathologist who is physician specially trained in diagnosing cancers.
Staging allows physicians to understand the extent of a patient’s cancer, helps guide treatment decisions and predict outcomes. Staging used by physicians for esophageal cancer is specific, but a straightforward way to describe staging is shown below:
A CAT scan obtains high resolution images using cross-sectional x-rays of the entire body from chest to abdomen. It is noninvasive and takes only a few minutes perform. These images help determine the size of the tumor and whether it has spread into lymph nodes or other organs. It is useful in staging esophageal cancer.
A PET scan is a noninvasive study that involves the injection of a radioactive sugar into the blood. The tracer is safe and rapidly passes out of the body. Cancer cells are more active than normal cells and pick up more of the tracer. During a PET scan, the patient lies in a special scanner with a camera that records the radioactive activity and creates a picture of areas involved by tumor. This test adds information on the stage of the cancer and will be ordered by your physician.
More specifically, esophageal cancer is staged by T stage (depth of the tumor into the wall of the esophagus, N stage (involvement of lymph nodes with cancer cells).
Your physician will inform you of the stage of your esophageal cancer and the best treatment options.
Esophageal cancer is diagnosed and treated by gastroenterologists (specialists of the gastrointestinal tract), thoracic surgeons (surgeons who specialize in esophageal surgery) as well as medical and radiation oncologists (doctors who treat cancers using chemotherapy or radiation therapy). These doctors work together to choose the best treatment for each patient dependent on the stage of the cancer (how advanced it is) and a patient’s overall medical condition. At the Baylor University Medical Center in Dallas, our team of experts works together to choose the best treatment for you.
The most important determinant of a patient’s prognosis is the stage of the cancer (the depth of the tumor into the wall of the esophagus, whether it is localized in esophagus or if it has moved) and a patient’s overall health condition. The treatment most likely to achieve a cure is chosen while being mindful of maintaining the patient’s quality of life.
In most cases, the treatment of esophageal cancer is determined by its stage. Localized cancers are treated by surgery. Regional cancers are treated by a combination of therapies including chemotherapy, radiation and surgery. Distant disease is treated by chemotherapy. Some very early cancers involving just the inner surface lining of the esophagus (mucosa) can be treated endoscopically. Portions of the mucosa are cored out (endomucosal resection or EMR) using specialized instruments. Other therapies to treat these very early cancers are laser, radiofrequency or thermal energy ablative techniques designed to kill the cancer cells and yet spare the remainder of the esophagus. Close endoscopic monitoring is performed to be certain that the cancer does not return. Your doctors will help choose the best treatment for you.
Surgery for esophageal cancer presents the best chance for cure in treating localized esophageal cancer and is considered the “gold standard” against which all other treatments are compared. Surgery for esophageal cancer requires the removal of most of the esophagus. The extent of the surgery is determined by the size and location of the tumor. In order for the patient to be able to eat, the stomach is freed up in the abdomen and connected to the upper portion of the esophagus, above where the tumor has been removed. With time, a patient will be able to resume eating most foods normally and return to good quality of life.
Most surgery for esophageal cancer can now be performed at Baylor University Medical Center using minimally invasive approaches such as VATS (video assisted thoracic surgery) or laparoscopically. Surgery for esophageal cancer should be performed by surgeons with specific training and focus on cancers of the esophagus.
Your surgeon will evaluate your fitness for surgery, whether your tumor is resectable (removable) and discuss the surgical approach (minimally invasive vs larger incisions).
Radiation therapy uses high-energy X-ray beams to kill cancer cells. It can be used alone as primary therapy or in conjunction with other therapies such as chemotherapy or surgery. It can be used to treat patients with advanced cancers to relieve pain and obstruction (blockage) of the esophagus and improve problems with swallowing. Additionally, it can be used to improve cure rates in patients with regional cancers when combined with chemotherapy and or surgery. Patient who have localized cancers but are not medically fit to undergo surgery due to other medical problems are typically treated with chemotherapy or radiation therapy alone. Your expert team at Baylor University Medical Center will work together to choose the best therapy for each patient (link).
Chemotherapy uses drugs designed to kill rapidly growing cancer cells while sparing normal ones. Chemotherapy is delivered through intravenous therapy although some recently developed chemotherapy drugs can be given as a pill. Newly developed “targeted” medicines use newly discovered weaknesses in the growth pathways of cancer cells and provide the potential for improved outcomes with less side-effects when compared to traditional IV approaches. All tumors evaluated at BUMC are tested for their unique genetic profile to determine whether they are candidates for treatment using these novel therapies (see link). Chemotherapy is used to treat patients whose tumors have been removed to prevent the recurrence (return) of their cancer and in patients whose tumors have spread (metastasized).