Overview

What is Oesophageal Cancer?

The oesophagus is the tube that connects the mouth and throat to the stomach. In the chest, it lies behind the windpipe or trachea. Further down, it passes through an opening in the diaphragm, the muscle that lies between the lungs and the stomach. After passing through the diaphragm, the oesophagus joins the stomach. Where the oesophagus joins the stomach is a valve to prevent food from passing backward from stomach to oesophagus. The cells of the inner lining of the oesophagus can become cancers.

How common is Oesophageal Cancer?

There is a decreasing trend for oesophageal cancer. Between 2005 to 2009, there were about 334 reported cases in Singapore. However, it is the 8th most frequent cancer deaths in Singapore among the males according to the Singapore Cancer registry.

Age of Onset

Oesophageal cancer occurs most commonly in the elderly. It is more common in men than women.

Causes and Risks

Nitrosamines and alcohol have been implicated in the high incidence of oesophageal cancer in certain countries. Nitrosamines are found as food preservatives.

Certain benign oesophageal diseases have been known to predispose to oesophageal cancer. Patients with achalasia, an oesophageal disease due to incoordinated contractions of the oesophagus leading to difficulty swallowing, have a seven times higher incidence of oesophageal cancer. Previous injury to the oesophagus due to caustic soda also predisposes to cancer. Conditions such as Barrett's disease where the lining of the oesophagus is different, Plummer-Vinson syndrome where a web forms over the opening of the oesophagus into the stomach, all predispose to oesophageal cancer.

Tylosis, an inherited condition characterised by thickening of the palms and soles, has a high association with oesophageal cancer.

Symptoms

Symptoms and Signs of Oesophageal Cancer

Most patients present with difficulty swallowing that becomes progressively worse. Initially, there is difficulty swallowing solid foods and then subsequently liquids are difficult to swallow. This leads to weight loss.

Symptoms of advanced disease include lumps in the neck and tummy, choking after food or repeated lung infections. There may also be hoarseness of voice.

Diagnosis

Diagnostic Tests

A fiber-optic tube, called an endoscope, is passed into the mouth and then into the oesophagus to look into the oesophagus and to biopsy any mass. Although uncomfortable this test is essential and takes about 30 minutes to complete. It is an outpatient procedure performed under light anaesthesia.

A special x-ray test called a barium swallow will also delineate the extent of the cancer. During this test, a liquid paste containing barium is swallowed. During the act of swallowing many x-rays of the oesophagus are taken. The barium outlines the lining of the oesophagus and the cancer within.

Computerised scans (CT) of the lungs and liver show if there is cancer elsewhere.

Treatment Options

Treatment of Oesophageal Cancer

Aggressive surgery to remove the cancer provides the patient a chance of cure. The cancer is removed together with a rim of normal tissue. The rest of the oesophagus or the stomach, if there is insufficient length of oesophagus, is joined to the upper oesophagus. Surgery is not without difficulty and some patients are not fit enough for it.

Patients with oesophageal cancer confined to the oesophagus but who are not fit for surgery may receive combined chemotherapy and radiotherapy. Using both methods of therapy may cure a small group of these patients. Radiotherapy is usually given daily over a period of 5 to 6 weeks. Side effects include difficulty eating because of pain, redness of the skin, and loss of appetite. Chemotherapy may be combined with the first and fifth week of radiotherapy to make radiotherapy more effective. Treatment is associated with nausea and vomiting, mouth ulcers, hair loss, and loss of appetite. Recent studies suggest that the use of surgery combined with chemotherapy and radiotherapy may be beneficial. Proper patient selection is important.

Patients with advanced incurable oesophageal cancer involving organs other than the oesophagus are sometimes given chemotherapy alone to slow the course of the cancer. However, if the main symptom is difficulty swallowing, radiotherapy is sometimes given to enable the person to eat.

Patients with oesophageal cancer who have difficulty eating and who are not fit for surgery or radiotherapy may have a feeding device inserted directly from the skin into their stomach. Another way of bypassing the blockage caused by the cancer is to pass a metal stent into the oesophagus through the cancer. Liquids can pass through this stent into the stomach and nourish the patient.

Prognosis of Oesophageal Cancer

Clinical examinations, x-rays and pathology reports all help the medical team decide what the progress of an individual case of oesophageal cancer may be. Then, the appropriate course of treatment will be put into action. The treatment strategy will vary from person to person. With prompt and appropriate treatment, the outlook for a person with oesophageal cancer is fair.