Oesophageal cancer treatment

This section provides information about oesophageal cancer. This includes its causes, risk factors, symptoms, how it is diagnosed and the different types of treatment available.

About oesophagus cancer

The oesophagus is the medical name for the food pipe (sometimes called the gullet), which is the long, muscular tube that carries food down your throat to the stomach. It’s part of your digestive system, and about 25cm long in adults (about 10 inches)^[i].

The upper part of the oesophagus sits behind your windpipe (called the trachea), while the lower part passes down through your chest between the spine and the heart.

When you swallow food, the muscles of the oesophagus wall contract to push the food down and into your stomach.

Oesophageal cancer facts

• Oesophageal cancer is rare, and is the thirteenth most common cancer in the UK^[ii]
• In the UK, 8,300 new cases were diagnosed in 2011[iii]
• More than 80% of oesophageal cancers occur in people aged 60 or over^[iv].

^[i] Macmillan Cancer Support, The oesophagus (gullet) https://www.macmillan.org.uk/Cancerinformation/Cancertypes/
Oesophagusgullet/Aboutoesophagealcancer/Theoesophagus.aspx
^[ii] Cancer research UK, Cancer statistics key facts https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/oesophageal-cancer
^[iii] Cancer research UK, Cancer statistics key facts
^[iv] Cancer research UK, Cancer statistics key facts

Types of oesophagus cancer

A cancer can occur anywhere along the length of the oesophagus, and there are two main types of oesophageal cancer:

• Squamous cell carcinoma, which develops in the thin, flat cells of the mucosa lining the oesophagus
• Adenocarcinoma, which develops in the glandular cells of the submucosal lining of the oesophagus, which produces mucus.

Squamous cell cancers occur more frequently in the upper and middle regions of the oesophagus. Hot liquids and sharp foods don’t easily damage squamous cells, and they can repair themselves. Adenocarcinomas are more common at the lower end of the food pipe, including where the oesophagus joins the stomach.

Over 95% of oesophageal cancers are either squamous cell carcinomas or adenocarcinomas^[v].

There are other more rare types of cancer of the oesophagus, and these include soft tissue sarcomas such as gastrointestinal stromal tumours (GISTs), which need different kinds of tests and treatments.

^[v] Macmillan Cancer Support, Types of oesophageal cancer (cancer of the gullet) https://www.macmillan.org.uk/Cancerinformation/
Cancertypes/Oesophagusgullet/Aboutoesophagealcancer/ Typesofoesophagealcancer.aspx

Causes and risk factors

The exact causes of oesophageal cancer aren’t understood, but a number of factors can put you at risk for each of the two main types of cancer described above^[vi]:

• smoking increases the risk of both types of oesophageal cancer
• drinking alcohol increases the risk of squamous cell carcinoma
• being overweight or obese increases your risk of adenocarcinoma of the oesophagus
• a condition known as Barrett’s oesophagus is a risk factor for adenocarcinoma of the oesophagus
• radiotherapy to the chest area (mediastinum) has also been linked to an increased risk of oesophageal cancer[vii], although this is very rare
• growing older
• men are about twice as likely as women to develop oesophageal cancer
• a diet high in animal fat and red meat and low in fresh fruit and vegetables can increase your risk.

^[vi] Cancer Research UK, Causes and risk factors https://www.nhs.uk/Conditions/Cancer-of-the-liver/Pages/Causes.aspx
^[vii] Cancer research UK, Cancer statistics key facts https://publications.cancerresearchuk.org/downloads
/Product/CS_KF_OESOPHAGUS.pdf

Oesophagus cancer symptoms and diagnosis

If you experience any of these symptoms you should visit your GP as soon as possible:

• difficulty swallowing (called dysphagia), where you feel that food is sticking in your throat. This is the most common symptom of oesophageal cancer, but it can be caused by more common conditions
• vomiting (being sick) or bringing food back up that hasn’t gone into stomach (called regurgitation)
• pain when you swallow
• unexpected weight loss
• pain or discomfort behind your breastbone or in your back
• painful indigestion or heartburn that doesn’t go away. Indigestion is very common and not usually caused by cancer, but you should still get it checked by a doctor if symptoms persist
• a cough
• hoarseness, which can sometimes happen if there’s pressure on the nerve attached to the voice box.

These symptoms can also be caused by conditions other than oesophageal cancer, but if they don’t go away after a couple of weeks, you should always tell your GP about them so you can treat any problems early.

Diagnosing oesophageal cancer
If you’re experiencing any of the symptoms of oesophageal cancer, you should see your GP first, who will examine you. If your GP isn’t sure of the problem, or suspects a cancer, they will refer you to hospital for specialist advice and treatment.

Before the consultant specialist examines you, they will ask about your general health and any medical problems.

At CircleI Health, you will have blood tests and a chest x-ray to check your general health, and the following tests may be used to diagnose cancer of the oesophagus:

• upper gastro-intestinal endoscopy, where a thin flexible tube with a tiny camera and light is gently passed down your oesophagus to see if there are any abnormal areas
• a biopsy might be taken during the endoscopy, where a sample of cells is taken from your oesophagus to be examined under a microscope
• a barium swallow might be needed. The test involves drinking a white, chalky liquid (containing barium) that reveals the inside of the oesophagus in greater detail on an X-ray.

Your consultant specialist may also do further tests to confirm the diagnosis, particularly to see if the cancer has spread to any other parts of the body. The tests might include:

• an endoscopic ultrasound scan of your oesophagus, which uses the same technique as the upper gastrointestinal endoscopy, but uses a tiny ultrasound probe to build a picture of your gullet
• a CT scan of takes a series of X-rays to build up a three-dimensional picture of your oesophagus, which can reveal any cancer in your gullet or other parts of your body
• a PET-CT scan is a combination of CT scan and PET scan. It gives detailed information about your cancer
• a laparoscopy helps your consultant surgeon to look inside your oesophagus using a thin, flexible tube with a camera on the end, called a laparoscope.

The results of the tests will also help to determine the appropriate treatment for you.

Stages of oesophageal cancer
After your tests, your consultant will tell you what stage your oesophageal cancer is at by looking at a sample of your cells under a microscope.

This describes how big your tumour is and how far it’s spread, and will influence the type of treatment you’re offered. There are several ways of staging cancers but the two main ones used for oesophageal cancer are the TNM system and the number system. 

The number system

• Stage 0 or high-grade dysplasia (severely abnormal cell changes), sometimes also called carcinoma in situ (CIS) – this means that there are severely abnormal cells in the inner lining of the oesophagus. Left untreated, some cells may change into an invasive cancer. People with Barrett's oesophagus are at risk of developing these abnormal cells
• Stage 1 is divided into stage 1A and 1B
  • Stage 1A means that the cancer is found within the oesophageal wall, and has not spread to nearby tissues, lymph nodes or other organs
  • Stage 1B means the cancer has grown into the muscle layer of the oesophageal wall, but has not spread elsewhere
• Stage 2 is divided into stage 2A and 2B
  • Stage 2A means the cancer has grown into the membrane covering the outside of the oesophagus, but has not spread to nearby lymph nodes
  • Stage 2B means the cancer has grown in the top two layers of the oesophagus, the lining (mucosa) and muscle layer, and is in one or two lymph nodes, and has not spread to any other organs
• Stage 3A means the cancer has grown into the tissue covering the lungs (pleura), the outer covering of the heart (pericardium) or the muscle at the bottom of the rib cage (diaphragm) but has not spread anywhere else, or it has grown into the membrane covering the oesophagus and is in one or more nearby lymph nodes
• Stage 3B means the cancer has grown into the membrane covering the oesophagus, and has spread to three to six lymph nodes but nowhere else
• Stage 3C means the cancer has grown into the tissue covering the lungs (pleura), the outer covering of the heart (pericardium) or the muscle at the bottom of the rib cage (diaphragm) and is in up to six lymph nodes, or it has grown into nearby structures like the windpipe (trachea), a spinal bone (vertebra) or a major blood vessel (the aorta) and has spread to any number of local lymph nodes
• Stage 4 means the cancer is advanced and has spread to other parts of the body, such as the liver or lungs^[viii].

^[viii] Cancer Research UK, the stages of oesophageal cancer https://www.cancerresearchuk.org/about-cancer/oesophageal-cancer/stages-types-and-grades

Treating oesophagus cancer

The type of treatment you’re offered depends on the type and stage of your oesophageal cancer. If your cancer is in the early stage and hasn’t spread to other parts of your body, your consultant may recommend surgery to remove part of or your entire oesophagus. You may also be offered chemotherapy and radiotherapy.

But if the oesophageal cancer is more advanced, or there are specific conditions involved (such as Barrett's oesophagus) surgery may not be recommended for you and other options will be discussed with you.

Surgery
If the oesophageal cancer is caught early and hasn’t spread to any other organs, surgery may be an option. Surgery for oesophageal cancer is a major operation that will remove some or all of your oesophagus, so it’s important that your consultant makes sure you are fit enough to make a good recovery.

Endoscopic mucosal resection (EMR)
If you have high grade Barrett's oesophagus, or a very early stage cancer that only affects the inside lining of the oesophagus (the mucosal layer), it may be possible to remove the cancer using endoscopic mucosal resection (EMR), where a tube called an endoscope is pushed gently down your throat to see inside your oesophagus and remove the cancer.

Chemotherapy
Your consultant specialist may suggest chemotherapy on its own or given before your surgery to treat oesophageal cancer. When chemotherapy is given before surgery it is called neo adjuvant chemotherapy, and is commonly used to treat oesophageal cancer. You may be offered chemotherapy following surgery and this can help to reduce the risk of cancer returning.

If the oesophageal cancer has spread to other parts of your body (this is advanced oesophageal cancer), you might be given chemotherapy on its own, which will help to control or reduce the cancer and it effects.

Combined chemotherapy and radiotherapy
In certain cases, you might be offered chemotherapy and radiotherapy together, which is also called chemoradiation. This may be given to you before surgery to help shrink the cancer, which then makes it easier to cut out.

If you are can’t have surgery, or you simply don’t want surgery, you might be able to have chemoradiation on its own, especially is you have squamous cell cancer that is near the top of your oesophagus, as chemoradiation is often effective for this type of cancer.

Radiotherapy
In some cases, you may be given radiotherapy on its own if you are unable to have chemotherapy or surgery – this is common for advanced oesophageal cancer.

Biological therapy
Biological therapies, sometimes known as targeted therapies, are treatments that act on processes in the cells. They can interfere with the growth of some types of cancer cells. They can also slow the growth of new blood vessels to the tumour.

Laser treatment and stents
If the cancer is blocking your and making it difficult for you to swallow, it’s likely you will need treatment to clear the blockage. To treat this, sometimes laser treatment is used to burn away the tumour, or a tube called a stent is inserted that allows food and drink to pass through the oesophagus.

Radiofrequency ablation (RFA)
This treatment uses heat to destroy the cancer cells and is occasionally used to treat very early oesophageal cancers.

Photodynamic therapy (PDT) 
This is also called a light sensitising treatment, and involves the use of lasers with a light sensitive drug to destroy cancer cells. PDT may be given to try to prevent high-grade Barrett's oesophagus developing into cancer, or if you can’t have an endoscopic mucosal resection (EMR) or surgery.

Paying for your treatment 
You have two options to pay for your treatment – your costs may be covered by your private medical insurance, or you can pay for yourself. Check with your private medical insurer to see if your diagnostic costs are covered under your medical insurance policy. If you are paying for your own treatment the cost of the procedure will be explained and confirmed in writing when you book the operation.

Ask the hospital for a quote beforehand, and ensure that this includes the consultant fees and the hospital charge for your procedure.

Want to know more?
If you’d like to read more about oesophageal cancer, treatment or living with oesophageal cancer, please visit cancerresearchuk.org.uk.