How to Diagnose and Treat Esophageal Cancer

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1Recognizing the Symptoms of Esophageal Cancer

2Diagnosing Esophageal Cancer

3Treating Esophageal Cancer

4Recovering From Surgery

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Article Summary

Although the prevalence of esophageal cancer is low, it has a relatively high mortality rate. According to the National Cancer Institute, the prevalence of esophageal cancer was 4 in 100,000 people per year in 2012 with a 5-year survival rate of 18%. Two primary types of esophageal cancer are recognized: adenocarcinoma and squamous cell carcinoma. The chance of recovering from esophageal cancer improves significantly if it is detected early, so knowing the signs and symptoms are crucial for getting proper diagnosis and treatment.

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Part 1

Part 1 of 4:

Recognizing the Symptoms of Esophageal Cancer

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   Pay attention to difficulty of swallowing. Difficulty of swallowing (also called dysphagia) is one of the most common symptoms of esophageal cancer.

   • During the early stages, you may feel occasional “sticking,” especially of harder foods (such as meat, bread, and apples) as you swallow. If this happens, see a doctor.
   • This condition will worsen as the cancer advances. Eventually, it may progress to a point at which you cannot swallow any solid food.
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   Monitor your weight. Unintentional weight loss, especially of ten pounds a month or more, could be a sign of cancer.

   • Many different kinds of cancer can produce weight loss, but in esophageal cancer, particularly, this symptom might be exacerbated by difficulty swallowing.
   • Vomiting within a few hours of eating is another possible symptom of esophageal cancer; vomiting and other GI related complications, such as diarrhea arise as the cancer spreads to the intestines.
   • Whether the issue turns out to be cancer-related or not, it’s best to see a doctor if you notice unexplained changes in your weight.
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   Take chest pain seriously. A feeling of pain around or behind your breastbone can indicate esophageal cancer. See your doctor if you are experiencing chest pain of any kind, and if the pain is severe, get help immediately.
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   Watch for a burning sensation in the chest. Some people with esophageal cancer have symptoms of indigestion or heartburn, characterized by an uncomfortable burning feeling in the chest. If you notice this symptom, make an appointment with your doctor.

   • Heartburn is caused by stomach acids irritating the esophageal lining after eating a meal, especially with spicy or overly-seasoned foods. If heartburn is not recognized and treated, it can put some people at risk for Barrett's, which is a pre-cancer condition that requires close monitoring.
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   Be aware of persistent hoarseness. If your voice becomes hoarse for no apparent reason, see a doctor. Consistent hoarseness can also be a sign of esophageal cancer.
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   Recognize your risk factors. Your family history (genetic factors) as well as past illnesses provide important clues about your risk of developing esophageal cancer.

   • If you have a history of Barrett’s esophagus or high grade dysplasia, you have an increased risk of developing esophageal cancer. Neither of these conditions are symptoms of cancer, per se, but they do warrant extra caution and regular monitoring.
   • Esophageal cancer is more common in men than in women.
   • Obesity can increase your risk of esophageal adenocarcinoma.
   • Squamous cell carcinoma seems to occur more frequently in people who drink, smoke, or are exposed to environmental factors that cause chronic irritation and inflammation of the esophagus.
   • Race also plays a role: adenocarcinoma is more common in white people, and squamous cell carcinoma is more common in black people.
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Part 2

Part 2 of 4:

Diagnosing Esophageal Cancer

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   Make an appointment with your doctor. If you have any of the symptoms of esophageal cancer, contact your doctor for an appointment. He or she will ask you about your symptoms and order appropriate tests.
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   Schedule a barium swallow. In consultation with your doctor, you may decide to schedule a barium swallow. During this test, you will swallow a chalky fluid, called barium, followed by X-ray imaging.

   • The barium swallow test reveals the inner structure of the esophagus, and with it, any small bumps or raised areas in the lining.
   • Please note that although a barium swallow can reveal the presence of an obstruction, it is not sufficient alone to diagnose esophageal cancer. Further tests, such as a biopsy, must be performed to make that diagnosis.
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   Have an endoscopic ultrasound with a fine needle biopsy. If your symptoms and/or the results of the barium swallow warrant it, your doctor may also do an endoscopic ultrasound (EUS) with a fine needle biopsy.

   • During this test, your doctor will look through your esophagus using a scope that is guided by an ultrasound. He or she will look for the plaques, nodules, ulcerations, or masses that are characteristic of esophageal cancer.
   • In addition, he or she will perform a biopsy by taking tissue from your esophagus for testing. This biopsy will show whether or not you have esophageal cancer and, if so, what type.
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   Schedule a Positron Emission Tomography - Computed Tomography Scan (PET/CT). If you do have esophageal cancer, your doctor may order a PET/CT, which is a sensitive imaging test that combines a PET scan with a CT scan.

   • During this exam, you will drink a liquid called 18-F fluorodeoxyglucose (FDG), wait for 30 minutes for your cells to absorb the solution, and then lie on a table as images are taken of your body, from your head to your knees.
   • Tumor cells, like regular cells, need glucose to survive, and they have a high metabolism rate; as a result, areas that “light up” on the scan provide information about the extent of your cancer and how aggressive your tumor cells are.
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   Understand your test results. Talk to your doctor about your specific circumstances. There are two main types of esophageal cancers: adenocarcinoma and squamous cell carcinoma. Further, in the United States and Europe, a “TNM” staging system is used to describe esophageal cancer.

   • The “T” indicates how deeply the tumor has penetrated through your esophagus.
   • The “N” indicates whether the lymph nodes around the esophagus have cancer cells in them.
   • The “M” indicates metastasis (cancer that has spread to any other areas of your body).
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Part 3

Part 3 of 4:

Treating Esophageal Cancer

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   Talk to your doctor about treatment. Your doctor can explain the different treatment options and what to expect.

   • The treatment options usually consist of a surgery, chemotherapy and radiation.
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   Understand your surgical options. Esophagectomy is one possible treatment for esophageal cancer. Although there are several variations of the operation, the underlying principle is the same – the surgeon removes the part of the esophagus with the tumor.

   • This operation will take place first in your abdomen (to free the stomach) and then in your chest to remove the part of the esophagus with cancer. This is followed by re-attaching the stomach to the remaining esophagus.
   • One common variation on the esophagectomy is an Ivor-Lewis esophagectomy. It can be done either transthoracic (with a large open incision in the chest) or minimally-invasive (using specialized equipment and robotic technology).
   • If done in the minimally-invasive way, you’ll have smaller incisions, less blood loss, fewer post-operative complications, a shorter hospital stay, and better preservation of pulmonary function after the operation.
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   Ask about chemotherapy. You doctor may decide that chemotherapy should be administered alone to manage symptoms or in conjunction with other treatment modalities. Chemotherapy consists of receiving cancer-killing drugs through an IV or oral medication.

   • Chemotherapy may be administered prior to surgery to shrink targeted tumors, or after surgery to kill any cancerous cells that are left behind.
   • If you are in poor health and cannot manage surgery, chemotherapy may be your main treatment modality.
   • Unfortunately chemotherapy drugs have many side effects, including nausea, vomiting, and hair loss. It is important you understand the possible adverse effects prior to therapy so you can prepare for them appropriately.
   • Chemotherapy can also be combined with radiation therapy, which is known as chemoradiation.
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   Ask about radiation therapy. Another treatment option for esophageal cancer is radiation therapy. Radiation therapy uses high-energy radiation to shrink cancerous tissues. Radiation therapy can be administered from outside the body or through a tube down the throat to make direct contact with the targeted tissue.

   • Your doctor may choose radiation therapy as an alternative to surgery if you are not healthy enough to undergo a surgical procedure.
   • Side effects of radiation therapy include skin irritation, nausea, and fatigue, among others.
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   Consult your doctor and ask if you need a feeding tube. Some patients with esophageal cancer require jejunostomy tubes (feeding tubes), either in the immediate post-operative period or for a longer time..

   • If you are unable to swallow food or unable to get enough nutrition through your mouth, the j-tube will be placed through your abdomen into the jejunum (the second part of your small intestine).
   • Liquid nutrients can be given through this tube. Ask your doctor about how long you will have to take your nutrition through a feeding tube.
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Part 4

Part 4 of 4:

Recovering From Surgery

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   Plan for the post-operative recovery period. Some surgeons send their esophagectomy patients to the intensive care unit briefly after surgery, while others admit patients directly to their hospital room.

   • Ultimately, you will have to teach your body how to eat again, which can be a slow process. Most patients are able to go home seven to ten days after surgery.
   • During the surgery, a j-tube will have been placed into your intestine. This will allow you to receive enteral feedings (tube feedings) during the healing process. They will be started slowly a day or two after your surgery and slowly increased in amount.
   • About seven days after your surgery, another barium swallow will be performed to ensure there are no leaks around the anastomosis (the region where your remaining esophagus was sewn to your stomach).
   • You will then start to sip water and other liquids, followed by advancing to soft foods.
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   Understand your at-home care. Before sending you home, the nurses and doctors will provide your caretakers with extensive information about how to care for you and manage your nutrition. A home health nurse may also be assigned to help you during the initial weeks after your surgery.
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   Know how your surgical treatment will affect your quality of life. In the months following surgery, you may experience difficulty swallowing, reflux, pain, and fatigue. You may also encounter what is called “dumping syndrome” – a problem that occurs when food goes into the small bowel too fast and cannot be digested properly.

   • Signs of “dumping syndrome” include flushing, nausea, cramping, and vomiting. Speak to your doctor, but know that it usually resolves itself within a short period of time.
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   Understand your long-term recovery. Some patients experience post-operative problems even three or more years after surgery. These problems can include shortness of breath, problems with eating, reflux, diarrhea, and fatigue.

   • Your doctor may recommend you take antacids or motility drugs to relieve some of these symptoms.
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   Follow up with your oncologist. Your oncologist can confirm that you don’t need any more treatment. He or she may want to see you on a routine basis for the foreseeable future, as well, in order to monitor your condition and make sure the cancer does not recur.
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Tips

• Because obesity and unhealthy lifestyle increases your risk of esophageal cancer, lower your risk by getting regular exercise, quitting smoking, limiting your alcohol intake, and talking to your doctor if you suspect you have been exposed to environmental factors that have irritated your esophagus.
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• Keep in mind that although esophageal cancer has been considered especially deadly in the past, advancements in treatment have made the prognosis much better for many patients. Keep calm, and talk to your doctor about all of your options.
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