Esophageal cancer is the 11th most common cancer in the world and the 7th most common cause of cancer death
Esophageal cancer is a type of malignancy that originates in the esophagus, the tube that connects the throat to the stomach. Its burden varies globally, with high-risk belts across central Asia and down the eastern side of Africa, and in these belts, 90% of the cases are esophageal squamous cell carcinoma (ESCC). In the United States, the majority of cases are adenocarcinoma of the esophagus (AdCA). The African high-risk belt largely follows the Rift Valley but extends south-ward to the Eastern Cape Province of South Africa. Many patients present with advanced-stage disease, with severe esophageal obstruction, and this, combined with limited treatment resources, typically results in survival of less than 6 months. ESCC is one of the most common fatal cancers in both sexes in most of these high incidence countries, but historically there has been little etiologic or clinical research or advocacy devoted to this disease. A unique feature of Africa’s ESCC belt is the young age of many patients. Most series report a mean age of patients in the 50s, with up to 18% of patients presenting before age 40, and a few cases presenting before 20 years of age. Such a young age distribution of cases is not seen anywhere else in the world, and it is not explained by the age distribution of the general population.
In high-income countries, the most important risk factors for ESCC are smoking tobacco and consumption of alcoholic beverages. In low- and middle-income countries, such as those in Africa, smoking and alcohol are not as common, and other risk factors appear to be more important. Indoor air pollution, caused by cooking and heating with biomass fuels (wood, coal, or dung) in poorly ventilated rooms, is a major risk factor, especially for women and small children who may spend up to 8 hours each day in this environment. Consuming very hot drinks may be a contributing factor, as is poor oral health. Changing these living conditions and habits should reduce the risk of ESCC.
The main reason that esophageal cancer is such a fatal disease is that symptoms usually occur late, only after the tumor significantly blocks the esophageal lumen, and by then the disease process is advanced. This late presentation results in 5-year survivals of about 20% in the US and less than 5% in Africa. To improve the survival in patients, high-risk asymptomatic individuals need to be identified and screened for early lesions. Identifying high-risk individuals can be done using knowledge of risk factors (age, gender, smoking, exposure to indoor air pollution, etc.), and screening can be done by endoscopic inspection, biopsy of suspect lesions, and endoscopic removal of lesions that turn out to be precursors of cancer or early cancer.
Such a program is now a national initiative in high-risk areas of China, and it has been shown to reduce ESCC mortality by about 33% over 10 years. However, such a screening program is too expensive for most places in Africa, so simpler, cheaper primary screening tests are still needed to refer only the most probable cases for endoscopic confirmation. Newer approaches are being tested. Learn more from Stories of Hope)
The treatment for esophageal cancer and the prognosis depends upon at which stage the cancer is found.
Stage I
Cancer limited to esophageal lining and has not spread to wall of esophagus or to lymph nodes
Stage II
Cancer has advanced to outer layer of esophagus but has not spread to lymph nodes
Stage III
Cancer has advanced into outer layer of the esophagus and spread to lymph nodes ( 6 or less) but not to distant organs
Stage IV
It is also referred to as metastatic cancer. It implies that the cancer has spread beyond the esophagus and regional lymph nodes to other organs and/or distant sites of the body
In most cases, the patient first sees a doctor when he/she has advanced disease (Stage 3 or 4). In this case, palliative treatment is usually the best option. If the resources are available, this most often results in having a stent placed to open the constructed esophageal passage. If the patient presents with Stage 1, early cancer, and the goal is cure with removal of the entire cancer. Most often this is done with surgical resection, but if the expertise is available endoscopic removal is possible. Individual decisions about treatment are more likely to vary when Stage 2 or 3 esophageal cancer is found.
Surgery to remove the cancer can be used alone or in combination with other treatments.
Procedures used for esophageal cancer may include:
A procedure to remove the cancer and some of the healthy tissue around it. The procedure is done through a long, flexible tube, called an endoscope.
Esophagectomy is surgery to remove part of the esophagus. During esophagectomy, the surgeon removes the part of the esophagus that contains the cancer and some nearby lymph nodes. The surgeon also may remove some of the upper part of the stomach. When the surgery involves removing some of the esophagus and some of the stomach it's called an esophagogastrectomy. The remaining esophagus is reconnected to the stomach. Usually this is done by pulling the stomach up to meet the remaining esophagus.
Chemotherapy treats cancer with strong medicines. They can be delivered intravenously or less frequently orally. Chemotherapy medicines are typically used before or after surgery in people with esophageal cancer. Chemotherapy can be combined with radiation therapy. In people with advanced cancer that has spread beyond the esophagus, chemotherapy may be used alone to help relieve symptoms caused by the cancer.
Radiation therapy treats cancer with powerful energy beams. For esophageal cancer, radiation therapy is most often done with a procedure called external beam radiation. During this treatment, you lie on a table while a machine moves around you. The machine directs radiation to precise points on your body. Radiation also can be placed inside your body near the cancer. This kind of radiation therapy, called brachytherapy, is less common.
Radiation therapy is often combined with chemotherapy in people with esophageal cancer.
Combining chemotherapy and radiation therapy may enhance the effectiveness of each treatment. Combined chemotherapy and radiation may be the only treatment you receive, or combined therapy can be used before surgery. But combining chemotherapy and radiation treatments increases the likelihood and severity of side effects.
Immunotherapy for cancer is a treatment with medicine that helps the body's immune system kill cancer cells. The immune system fights off diseases by attacking germs and other cells that shouldn't be in the body. Cancer cells survive by hiding from the immune system. Immunotherapy helps the immune system cells find and kill the cancer cells.
For esophageal cancer, immunotherapy is sometimes used before or after surgery. It also may be used for advanced cancers that can't be removed with surgery or for cancers that come back after treatment.
Palliation may be used to treat specific symptoms like dysphagia (difficulty swallowing) by insertion of an esophageal stent. Or it may be used to manage pain or breathing difficulties. In the most advanced situations palliation may involve Hospice Care
