What Is Asbestos

What Is Cancer of the Esophagus?

The esophagus is a muscular tube that connects the mouth to the stomach. It carries food and liquids to the stomach. It is about 10-13 inches long. At its smallest point, it is a little less than one inch wide.

The wall of the esophagus has several layers. Cancer of the esophagus starts from the inner layer and grows outward.

At the top of the esophagus is a special muscle called a sphincter relaxes to let food or liquid enter. The lower part of the esophagus connects to the stomach. Another muscle here opens to allow food to enter the stomach. This muscle also keeps stomach acid and juices out of the esophagus. When stomach juices escape into the esophagus, we feel heartburn. The medical term for heartburn is reflux.

Long-term reflux of stomach acid into the esophagus sets up a special problem. It can change the cells in the lower end of the esophagus. They become more like the cells that line the stomach. These changed cells produce a condition called Barrett esophagus. The altered cells can change into cancer, so they should be closely watched by a doctor.

There are 2 main types of cancer of the esophagus:

One type grows in the cells that form the top layer of the lining of the esophagus. These are called squamous cells, and cancer that starts there is known as squamous cell carcinoma. Squamous cell cancer can grow anywhere along the length of the esophagus. It accounts for about half of all cancers of the esophagus.
The other type usually starts near the opening to the stomach. It is called adenocarcinoma. This type of cancer cannot start unless squamous cells have been changed by acid reflux.
How common is cancer of the esophagus?
The American Cancer Society estimates that there will be about 14,550 new cases of this cancer in 2006 in the United States. About 13,770 people will die of the disease. This cancer is 3 to 4 times more common among men than among women and 50% more common among African Americans than among whites. Some countries such as Iran, northern China, India, and southern Africa have rates that are 10-100 times higher than the United States.

What Causes Cancer of the Esophagus?

While we don't know the exact cause of esophageal cancer, we do know some of the risk factors. Some risk factors, such as smoking, can be controlled. Others, like a person's age or race, can't be changed.

Risk Factors

Age: The risk of this cancer goes up with age. It is rarely found in people under 40.

Sex: Men are 3 times more likely to get this cancer than women.

Race: African Americans are 50% more likely to develop cancer of the esophagus than whites.

Barrett esophagus: This occurs because of long-term reflux of fluid from the stomach into the lower esophagus. Some people feel heartburn from this reflux and others do not. Over time this reflux can change the cells at the end of the esophagus. This raises the risk of adenocarcinoma of the esophagus. But not everyone with Barrett esophagus will get cancer of the esophagus.

Heartburn: Long-standing heartburn, also called reflux (or GERD: gastroesophageal reflux disease), increases the risk of this cancer even if it hasnÂ’t progressed to Barrett esophagus.

Tobacco: Using any form of tobacco raises the risk of this cancer. The longer a person uses tobacco, the greater the risk. More than half of all squamous cell esophageal cancer is linked to smoking.

Alcohol: Long-term heavy drinking is a major risk factor for cancer of the esophagus. For people who both smoke and drink, the risk is further increased.

Overweight: The risk of this cancer is higher for people who are overweight or obese.

Diet: Diets that donÂ’t include enough fruits or vegetables and certain minerals and vitamins can raise the risk of this cancer. Overeating, which leads to being overweight, also raises the risk of this cancer.

Very hot liquids: Drinking lots of very hot liquids might increase the risk of this cancer.

Chemicals: Working with a chemical used in dry cleaning may lead to a greater risk of this cancer. Dry cleaning workers have a higher rate of cancer of the esophagus. Also, breathing in many other chemical fumes may also increase the risk.

Lye: Lye is found in strong cleaners like drain cleaners. It can burn and destroy cells. If a child accidentally drinks one of these cleaning liquids, the lining of the esophagus will scar. A child who has swallowed lye has a higher risk of squamous cell cancer as an adult.

Achalasia: In this disease, the muscle at the bottom of the esophagus does not open to release food into the stomach. So the lower end of the esophagus expands. Food collects there instead of moving into the stomach. This raises the risk for squamous cell cancer.

Tylosis: This is a rare, inherited disease. Extra skin grows on the palms of the hands and soles of the feet. People with tylosis are at a very high risk for esophageal cancer. They should be seen by a doctor regularly.

Esophageal webs: These are abnormal pieces of tissue that extend into the esophagus. They can make it hard to swallow. People who have these usually have other symptoms as well. They can have problems with the tongue, fingernails, spleen, and other organs. About 1 in 10 people with this problem will get cancer of the esophagus.

How Is Cancer of the Esophagus Found?

People with Barrett esophagus and others at high risk should have exams to look for cancer of the esophagus. The doctor might recommend surgery (or other methods) if certain abnormal cells (dysplasia) are found.

In most cases, this type of cancer is found because of the symptoms it causes. But often these symptoms don’t appear until the cancer is advanced, making a cure less likely. If the cancer is found early, it is often a result of tests done for other reasons.

Below are the most common symptoms of this type of cancer:

Trouble with swallowing (dysphagia: dis-FAY-jee-uh): This is the most common symptom of cancer of the esophagus. It means that you feel as if food is lodged in the chest. By this time, if cancer is present it has grown to fill about half the opening of the esophagus. Solid foods like bread and meat often get stuck. People with dysphagia often switch to softer foods or even liquids to help with swallowing. To help the food go down, the body makes more saliva. This causes some people to bring up lots of thick mucus or saliva.

Pain: Rarely, pain in the mid-chest, or a feeling of pressure or burning, can be a sign of cancer. But these symptoms can also be caused by something else, such as heartburn. Pain while swallowing is usually a late sign of a large cancer.

Weight loss: About half of people with esophageal cancer lose weight without trying. This is because they are not getting enough food since they have trouble swallowing. Also, they may find they have less appetite.

Other symptoms: Hoarseness, hiccups, pneumonia, and high calcium levels are usually signs of more advanced cancer. Of course, these symptoms can be caused by other diseases as well
If Cancer Is Suspected

If certain symptoms suggest that you may have esophageal cancer, your doctor will use one or more methods to find out if the disease is really present. After asking questions about your health and symptoms and doing a physical exam, your doctor will tell you which of the tests below you will need.

Barium swallow or Upper GI X-rays: This is a series of x-rays taken after the patient swallows barium, a dense liquid. Barium coats the surface of the esophagus and helps create a good picture. Any lumps on the lining of the esophagus show up on the x-ray. A barium swallow is often the first test to be done in people who have trouble swallowing.

Upper Endoscopy (en-DOS-kuh-pe): An endoscope is a flexible tube with a light and video camera on the end. The doctor uses this to look at the esophagus and the stomach. The patient is given a sedative before the tube is passed down through the mouth and esophagus into the stomach.

This test is useful because:

The doctor can see the esophagus clearly.
A tissue sample can be taken to find out if there is cancer and if so, what type it is.
If the cancer is blocking the opening of the esophagus, the opening can be made bigger.
The doctor can learn more about whether the cancer can be removed with surgery.
CT scan (computed tomography): A CT scan is a type of x-ray that takes many pictures. These pictures are combined by a computer to give a detailed view of organs inside the body. CT scans take longer than regular x-rays and the patient has to lie still on a table while the pictures are being done. A CT scan can be helpful in finding out the extent of the cancer, which in turn can help guide choices about surgery.

CT scans can also be used to guide a biopsy needle into an area that might be cancer. The needle is used to remove a sample of tissue for study in the lab.

Endoscopic ultrasound: This test uses an endoscope with a small ultrasound probe attached. It is like the ultrasound that doctors use to take pictures of the fetus during pregnancy. The ultrasound can show how far the cancer has grown into the esophagus to help in making choices about surgery. Recent studies suggest that it might be more accurate than CT scans or upper endoscopy.

Bronchoscopy (bron-KOS-kuh-pe): This test is somewhat like an endoscopy except that the doctor looks into the windpipe and the tubes leading into the lungs to see if the cancer has spread there. The patient will be made drowsy for this test.

PET scan (positron emission tomography): For this test, a special radioactive sugar is injected into a vein. The tissues with cancer quickly take up the sugar. Then a scanner can spot those areas. This test is useful for spotting cancer that has spread to nearby lymph nodes or other places in the body. It may help in staging the cancer.

Thoracoscopy (thor-uh-COS-kuh-pe) and laparoscopy (lap-uh-ROS-kuh-pe): These are methods that allow the doctor to see lymph nodes inside the chest or abdomen with a hollow lighted tube. The doctor can also remove lymph nodes for testing through the same tube. This information is helpful in telling whether surgery is a good option. For these tests the patient is in the hospital and is put into a deep sleep (general anesthesia).

Biopsy: This is the most important test. Tissue that was removed by other methods is looked at under the microscope in order to see if cancer is present and to find out what type of cancer cells there are. It usually takes a few days to get the results.

After The Tests: Staging

Staging is the process of finding out how far cancer has spread. This is very important because your treatment and the outlook for your recovery depend on the stage of your cancer.

This kind of cancer is staged using the results of the tests described above. Stages are often labeled using Roman numerals 0 through IV (0-4). In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more serious cancer. Stages II and IV can also be further divided into sub-stages A and B.
How Is Cancer of the Esophagus Treated?

After the cancer is found and staged, your doctor will talk to you about a treatment plan.

Surgery, chemotherapy, and radiation are used to treat early cancer of the esophagus.
There are also treatments to help relieve pain and help with symptoms.
The best choice for you will depend on the stage of the cancer as well as your general health. Each kind of treatment might have side effects. Your cancer care team will be glad to discuss the side effects with you.

Surgery

How much surgery is done depends on the stage of the cancer. Surgery can also be used along with other treatments such as chemotherapy and radiation treatment.

There are 2 common types of operations for this cancer.

Esophagectomy (ee-sof-uh-JEK-tuh-me): the part of the esophagus with cancer and nearby lymph nodes are removed. The esophagus is attached either to the stomach or the surgeon may replace the removed part of the esophagus with a piece of the small or large intestine.
Esophagogastrectomy (ee-sof-uh-go-gas-TREK-tuh-me): is done to remove part of the lower esophagus, nearby lymph nodes, and the upper part of the stomach. The esophagus is again connected to the remaining part of the stomach.
While surgery can cure some patients whose cancer has not spread beyond the esophagus, often these cancers are not found early enough.

Both of these operations are complex. Some surgeons are able to do the operation using a laparoscopic approach. This means that small cuts are made through which the doctor uses a tiny instrument something like a telescope to look inside the body. The surgery itself is done through even smaller incisions.

Surgeons who do this surgery must be quite expert. You should feel free to ask your surgeon about his or her experience with these operations and what percent were successful. The success rate is greater when the surgery is done in a hospital where it is done more often.

Most people stay in the hospital for 2 weeks after surgery. And there can be risks and side effects. For example, after the operation the stomach may empty very slowly, causing nausea and vomiting. The place where the esophagus connects to the stomach can become more narrow, making it hard for the person to swallow. Also, acid from the stomach can enter the esophagus causing heartburn. Anyone who has problems with side effects should talk with their doctor or nurse as there are often ways to help.

Some complications from surgery can be very serious, even fatal. It is important to have a surgeon with experience in a hospital where these operations are done more often. Don’t be afraid to ask the surgeon about his or her experience and about the survival rates at the hospital.

Radiation Therapy

Radiation therapy is treatment with high energy rays (such as x-rays) to kill or shrink cancer cells. External radiation uses a beam from outside the body. This is the kind most often used for cancer of the esophagus. For internal or implant radiation, radioactive “seeds” are placed directly inside the body near the cancer.

Radiation therapy by itself will not cure esophageal cancer. Often it is combined with surgery and/or chemotherapy. It is also used to relieve problems with swallowing, pain, or other symptoms of this cancer.

Side effects of radiation treatment may include skin problems, upset stomach, diarrhea, and fatigue. Often these side effects go away when treatment ends. Radiation to the chest may cause lung damage and lead to trouble breathing and shortness of breath. If you have these or other side effects, talk with your doctor since there are often ways to relieve them.

Chemotherapy

Chemotherapy refers to the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they spread throughout the body.

Chemotherapy alone cannot cure cancer of the esophagus unless radiation treatment (and in some cases surgery) are also used. Chemotherapy is used in 3 ways:

It can be used to ease the symptoms of advanced cancer.
It can be given along with radiation to shrink the cancer.
It can be used before surgery to shrink a tumor. This use is still being studied.
Chemotherapy can have some side effects. These side effects will depend on the type of drugs given, the amount taken, and how long treatment lasts. The most common side effects can include:

nausea and vomiting
loss of appetite
hair loss
mouth sores
increased chance of infection (from a shortage of white blood cells)
bleeding or bruising after minor cuts or injuries (from a shortage of blood platelets)
tiredness or shortness of breath (from a shortage of red blood cells)
Most side effects go away once treatment is over. Anyone who has problems with side effects should talk with their doctor or nurse as there are often ways to help.

PDT (photodynamic therapy): This method may be used when the cancer has been found very early or has come back after other treatment. First, a harmless chemical is injected into the bloodstream. It collects in the tumor for a few days. Then a special type of laser light is focused on the cancer through an endoscope. The light changes the chemical into a new chemical that can kill cancer cells.

PDT is useful because it can kill cancer cells with very little harm to normal cells. But because the light must be used, it can reach only cancers near the surface of the esophagus. It doesn’t work for cancers that have spread deeper or into other organs.

Side effects of PDT include redness or discoloration of the skin and sensitivity to the sun or other light sources. Because of this, people having this treatment may be told to stay indoors for 6 weeks.

At this time, the main use of PDT is to relieve symptoms of advanced cancer that are blocking the esophagus. It is also being used to treat Barrett esophagus and very early cancers found in Barrett esophagus. Researchers are looking at the use of PDT in comparison to other treatments such as surgery or the use of lasers.