Esophageal cancer

• Difficulty in swallowing (dysphagia)
• Pain or discomfort in the throat or back
• Chest pain or discomfort, particularly when eating or swallowing
• Frequent heartburn or acid reflux
• Chronic cough
• Hoarseness of voice
• Regurgitation of food or blood
• Vomiting, sometimes with blood
• Frequent hiccups
• Tiredness
• Unintentional weight loss

Note: Symptoms of esophageal cancer can differ from person to person, and some may not appear until the cancer is advanced. Access quality care and support throughout this journey if you or your loved one is fighting cancer.

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Esophageal cancer affects the tubular passage connecting the mouth to the stomach and primarily originates in the mucosa, the moist lining of the esophagus. Here's an overview of what happens during cancer:

• DNA, the genetic material, governs cell behavior, growth, division, and cell death.
• Some genes oversee the timing of cell growth, division, and death, including:
• Oncogenes, which promote cell growth, division, and survival.
• Tumor suppressor genes, which regulate cell division and trigger cell death when necessary.

Esophageal cancer can stem from DNA mutations that activate oncogenes or deactivate tumor suppressor genes, leading to uncontrolled cell growth and abnormal mass formation in the esophagus.

Esophageal cancer, like many other types of cancer, has several risk factors that may increase the likelihood of developing the disease. The primary risk factors for esophageal cancer include:

• Age: The risk of esophageal cancer increases with age, and it is more commonly diagnosed in older adults between the ages of 45 and 70 years.
• Gender: Men are more likely to develop esophageal cancer than women.
• Family or personal history of cancer: Individuals who have had head and neck cancer or esophageal cancer in the past may have a higher risk of developing esophageal cancer. A positive family history of cancer can also increase the risk.
• Medical conditions:
  • Gastroesophageal reflux disease (GERD)
  • Barrett's esophagus (a condition where the normal lining of the esophagus is replaced by a tissue that is similar to the lining of the intestine)
  • Plummer-Vinson syndrome (characterized by a triad of symptoms: iron deficiency anemia, difficulty swallowing (dysphagia), and esophageal web formation)
• Lifestyle choices:
  • Obesity
  • Physical inactivity
  • Tobacco smoking
  • Alcohol use
  • Diet rich in processed, packaged food, red meat, and low in fruits and vegetables
  • Consumption of very hot liquids
• Other factors:
  • Achalasia (a rare disorder where the muscular ring between the esophagus and stomach fails to relax properly)
  • Human papillomavirus (HPV) infection
  • Injury to the esophagus

To arrive at the diagnosis of any kind of cancer, it is important to understand its staging. Staging is essential to determine the extent of the disease.

Staging of Esophageal Cancer

The primary staging system used is the TNM system, which evaluates:

• T (Tumor): This indicates how deeply the tumor has invaded the layers of the esophagus wall and the surrounding tissue.
• N (Lymph Nodes): It assesses whether cancer has spread to nearby lymph nodes and, if so, how close they are to the original tumor.
• M (Metastasis): This assesses whether cancer has spread to other parts of the body.

Based on these criteria, esophageal cancer is categorized into the following stages:

• Stage 0 (Carcinoma in situ): Abnormal cells are present in the top layers of the esophagus, which could develop into cancer in the future.
• Stage 1: At this stage, cancer is confined to the thick muscle layer of the esophageal wall and hasn't spread beyond.
• Stage 2: The cancer has penetrated deeper layers of the esophagus and may have affected nearby lymph nodes.
• Stage 3: Cancer cells are found in all layers of the esophagus and may have also spread to adjacent organs.
• Stage 4: Cancer has spread to distant organs or lymph nodes, often the liver, lungs, or distant lymph nodes.

The diagnostic process may include the following steps:

1. Medical History and Physical Examination: The first step in diagnosing esophageal cancer is discussing your medical history and symptoms with a healthcare provider. They will perform a physical examination to check for any signs of the disease.
2. Imaging Tests:
   • CT scan: A computed tomography (CT) scan provides detailed cross-sectional images of the chest and abdomen, which can help determine the extent of the cancer and identify nearby lymph node involvement.
   • PET scan: A positron emission tomography (PET) scan is used to detect areas of increased metabolic activity, which can indicate the spread of cancer.
   • Barium swallow test: This test helps identify any abnormalities in the esophagus, such as tumors or strictures. You will be asked to drink a contrast material containing barium, which is visible on X-rays.
3. Endoscopy: It is a procedure using a flexible tube with a camera to check the body. It helps diagnose and assess esophageal cancer. It includes:
   • Upper endoscopy: It helps determine tumor size and spread, vital for surgery planning.
   • Endoscopic ultrasound: Used to measure cancer size and spread into nearby areas. It can also check lymph nodes for cancer.
   • Bronchoscopy: It may be performed to check if esophageal cancer has spread to the windpipe or lung tubes.
   • Thoracoscopy and laparoscopy: Thoracoscopy examines the chest cavity, while laparoscopy examines the abdomen. They are used to determine cancer spread and surgical suitability. These procedures are done in the operating room under anesthesia.
4. Cytology: It is the study of cells, and it is used in esophageal cancer to examine cell samples for abnormalities. It includes:
   • Brush cytology: This is a technique where cells from the esophagus lining are brushed and examined under a microscope to check for abnormalities.
   • Balloon cytology: In this procedure, cells are gathered from the esophagus lining using a deflated balloon that's ingested by the patient. The balloon is later inflated and withdrawn from the esophagus. Esophageal cells on the balloon are analyzed under a microscope to detect any irregularities.
5. Biopsy: Tissue samples taken during the endoscopy are sent to a pathology laboratory to be analyzed by a pathologist. This is a definitive way to confirm the presence of cancer, identify its type (adenocarcinoma or squamous cell carcinoma), and assess its grade and stage.
6. Blood Tests: Certain blood tests are conducted to help in the diagnosis of esophageal cancer. They include:
   • Complete blood count (CBC): This test measures the different types of cells in your blood. It can identify signs of anemia, which may be induced by bleeding tumors.
   • Liver function test: A blood test to check your liver function because esophageal cancer can sometimes spread to the liver.
7. Biomarker Testing of the Tumor: Analysis of tumor samples to identify unique genes, proteins, and factors can help determine treatment options. These include:
   • HER2 testing: Biopsy samples from advanced esophageal cancer may be tested for the HER2 gene or protein. Excessive HER2 can promote cancer growth, and drugs targeting these HER2 proteins may help treat these cancers.
   • PD-L1 testing: Some esophageal cancers are assessed for the PD-L1 protein level, as tumors with more PD-L1 may respond better to immunotherapy drugs.
   • MMR and MSI testing: Testing is done to check for high levels of microsatellite instability (MSI) or changes in mismatch repair (MMR) genes in esophageal cancer cells. Positive results might indicate suitability for immunotherapy in cases where surgery is not an option or the cancer has recurred or spread.

Preventing esophageal cancer involves adopting a combination of lifestyle changes and risk-reduction strategies. Here are some preventive measures:

1. Break free from smoking
   Smoking is a significant risk factor for esophageal cancer, particularly squamous cell carcinoma. You can greatly lower your risk by quitting smoking. Explore our smoking cessation range.
2. Cut down on alcohol
   Excessive alcohol consumption is another major risk factor for esophageal cancer. Abstain from alcohol or limit it to one drink per day for women and up to two drinks per day for men.
   Note: A drink means a 5-ounce glass of wine, a 12-ounce beer, or a 1.5-ounce shot of spirits.
3. Be mindful of your diet
   Consume:
   • A balanced diet rich in fruits and vegetables such as berries, citrus fruits, leafy greens, broccoli, and carrots.
   • A diet high in fiber and antioxidants.
   • Rich sources of omega-3 fatty acids and polyunsaturated fats.
   Avoid:
   • Highly processed food.
   • Sugary snacks and drinks.
   • Fast food.
   • Pre-packaged food loaded with chemicals and preservatives.
   • Red meat.
4. Watch your weight
   Obesity is linked to a higher risk of esophageal adenocarcinoma. Maintaining a healthy weight through a balanced diet and regular exercise can help reduce this risk.
5. Manage acid reflux
   Avoid trigger foods, elevate the head of your bed, and consult a doctor if symptoms persist, as gastroesophageal reflux disease (GERD) increases the risk of esophageal adenocarcinoma.
6. Screen for early detection
   If you are at high risk for esophageal cancer, talk to your healthcare provider about regular screening.
7. Try chemoprevention
   Some studies suggest that regular, long-term aspirin use may reduce the risk of esophageal cancer, particularly in those with Barrett's esophagus. Talk to your doctor before starting regular NSAID use.

Treatment typically involves a combination of therapies, including surgery, chemotherapy, radiation therapy, targeted therapy, and immunotherapy. Here's an overview of the treatment options for esophageal cancer:

I. General Treatment Measures

• Palliative Care: Focuses on providing relief from symptoms and side effects of cancer, improving the patient's quality of life, and managing pain.
• Nutrition Therapy: Esophageal cancer can disrupt normal nutrition intake, leading to malnutrition and dehydration. Your treatment strategy may involve a phase of body recovery and fortification before addressing the cancer itself. Dietitians can help with customized diets for swallowing issues and may recommend intravenous nutritional therapy to provide essential nutrients directly into your bloodstream.

II. Local Treatment

• Surgery:
  • Esophagectomy: The most common surgical procedure for esophageal cancer, involving the removal of part or all of the esophagus and reconstruction. The choice of surgery depends on the location and extent of the tumor.
  • Lymph Node Dissection: During surgery, nearby lymph nodes are often removed and examined to determine if the cancer has spread.
• Radiation Therapy: Uses high-energy X-rays or other particles to target and destroy cancer cells. It is of two types:
  • External-Beam Radiation Therapy: The most common type, where radiation is administered externally via a machine.
  • Internal-Beam Radiation Therapy (Brachytherapy): Involves the application of a radioactive source near the tumor using implants.
• Endoscopic Treatment:
  • Endoscopic Mucosal Resection: Used for dysplasia (pre-cancer) and early-stage esophageal cancers, involving the removal of abnormal tissue with instruments passed through the endoscope.
  • Photodynamic Therapy (PDT): Used for Barrett's esophagus, dysplasia, early-stage esophageal cancers, and to relieve obstruction in advanced cancers. Involves injecting a light-activated drug that accumulates in cancer cells, activated by laser light to kill cancer cells.
  • Radiofrequency Ablation (RFA): A balloon with electrodes is inserted via endoscopy to deliver an electrical current to kill abnormal cells, allowing normal cells to replace the treated area over time.
• Treatments to Keep the Esophagus Open:
  • Laser Ablation: Uses a laser beam through an endoscope to open a blocked esophagus due to advanced cancer, often requiring repeated procedures.
  • Argon Plasma Coagulation: Similar to laser ablation but uses high-temperature argon gas to relieve esophageal blockage.
  • Electrocoagulation (Electrofulguration): Burns tumors off with electric current, helpful for relieving esophageal blockage.
  • Esophageal Stent: A mesh device placed into the esophagus to keep it open, typically made of metal or plastic and used after other endoscopic treatments.

III. Systemic Treatment

• Chemotherapy: Treatment with anti-cancer drugs injected into a vein or taken by mouth, allowing them to reach most parts of the body. Drugs used for chemotherapy include:
  • Carboplatin
  • Paclitaxel
  • Oxaliplatin
  • Capecitabine
  • Cisplatin
  • 5-Fluorouracil (5-FU)
  Types of chemotherapy include:
  • Adjuvant Chemotherapy: Given after surgery, sometimes coupled with radiation therapy, aimed at preventing recurrence and eradicating remaining cancer cells.
  • Neoadjuvant or Induction Chemotherapy: Used prior to surgery to reduce the size of larger malignancies, potentially resulting in less severe surgical side effects.
  • Chemotherapy for Advanced Cancers: Reduces tumor size and alleviates symptoms in cancers that have progressed to other organs, often prolonging life.
  • Chemoradiation: Often combined with radiation therapy, as chemotherapy alone rarely cures esophageal cancer.
• Targeted Therapy: Uses medicines designed to target specific molecules or proteins involved in cancer cell growth, applicable in advanced or metastatic esophageal cancer. Some targeted drugs include:
  • Trastuzumab
  • Ramucirumab
  • Entrectinib
  • Larotrectinib
• Immunotherapy: Utilizes medicines to enhance the immune system's ability to find and destroy cancer cells. It typically works on specific proteins involved in the immune response. Drugs used include:
  • Pembrolizumab
  • Nivolumab

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Home care for esophageal cancer patients involves adapting your diet and eating habits to support your recovery and manage potential post-surgery challenges, such as reflux, nausea, fullness, diarrhea, and swallowing difficulties. Some herbs and supplements may alleviate side effects or improve overall well-being. For example:

• Aloe vera: Some studies suggest that aloe vera may help reduce inflammation and enhance the immune system, which can be beneficial for cancer patients.
  How to consume: It can be consumed in various ways, such as in the form of aloe vera juice or supplements.
• Ginger (Adrak): It has anti-inflammatory and antioxidant properties, which can help alleviate nausea and vomiting, common side effects of cancer treatments like chemotherapy.
  How to consume: It can be consumed in various forms, including fresh ginger root, ginger tea, ginger supplements, or as an ingredient in cooking.
• Turmeric (Haldi): It contains an active compound called curcumin that has shown potential in slowing the growth of cancer cells and inhibiting the spread of cancer in preclinical studies. It can also help manage inflammation and alleviate symptoms.
  How to consume: It can be consumed as a spice in cooking, taken as a supplement, or in the form of turmeric tea.

Note: Always consult your doctor before using any herbal remedies.

Esophageal cancer can lead to various complications, including:

• Functional gastric emptying disorder: Following surgery or treatment, individuals may experience difficulties with the normal emptying of the stomach, leading to delayed gastric emptying.
• Severe diarrhea and reflux esophagitis: Treatment and surgery for esophageal cancer can cause digestive issues, including severe diarrhea and gastroesophageal reflux disease (GERD), resulting in acid reflux and inflammation of the esophagus.
• Pulmonary infection: As food or liquids are aspirated into the lungs due to swallowing difficulties, it can result in pulmonary infections, potentially leading to pneumonia and other respiratory issues.
• Chylothorax: This is the accumulation of lymphatic fluid (chyle) in the chest cavity that can occur in some cases, leading to breathing difficulties. It may require drainage and management.
• Anastomotic fistula: This condition occurs when a surgical connection (anastomosis) between two parts of the digestive tract, typically the esophagus and stomach, develops a leak or fistula, leading to infection and further surgical interventions.
• Complications from treatment: Chemotherapy, radiation therapy, and surgery can have their own set of complications, including infection, scarring, and long-term side effects.

Note: Advanced stages may result in cancer spreading to vital organs such as the liver, lungs, bones, adrenal glands, kidneys, and brain via the bloodstream.

Complementary and alternative therapies can be considered alongside conventional medical treatments for esophageal cancer after consultation with your medical team. Some complementary therapies may include:

• Acupuncture: Involves the insertion of needles through the skin at specific points on the body. Acupuncture has proven to be a successful alternative therapy for patients with esophageal cancer, easing symptoms such as nausea and vomiting, which are common side effects of cancer treatments.
• Aromatherapy: Utilizes essential oils to alleviate pain, nausea, stress, and sleep difficulties during cancer treatment, promoting relaxation and comfort.
• Hypnosis: Conducted by a therapist who guides you through relaxation exercises to encourage positive and calming thoughts. It also helps reduce nausea and anxiety in individuals with cancer.
• Relaxation exercises: Techniques such as breathing exercises, meditation, mindfulness, guided imagery, and visualization can help manage pain perception and reduce stress. These practices improve quality of life and enhance mental well-being. Practicing meditation for just 10-15 minutes a day can significantly aid in disease management.
• Yoga: Incorporates breathing techniques, gentle movement, mindfulness, and meditation to optimize healing and well-being, promoting physical and emotional balance. Yoga benefits not only cancer patients but also enhances overall mental health and well-being.
• Music therapy: Listening to calm and soothing music can promote healing and improve quality of life.
• Tai chi: A mind-body practice that enhances health and well-being through movement, meditation, and breathing. It has been shown to help some individuals improve strength and balance, alleviating cancer symptoms.

Living with cancer means different things to different people. Considerations for caregivers and patients include:

1. Managing Emotions
   • Obtain all necessary information regarding treatment.
   • Communicate with loved ones.
   • Join support groups.
   • Initiate palliative care for symptom relief.
   • Seek assistance with practical issues like financial expenses, childcare, and work-related matters.
2. Post-Surgery Diet Guidelines
   • Opt for six small meals post-esophageal cancer surgery to accommodate reduced stomach capacity.
   • Start with ½ to 1 cup portions, gradually increasing; prioritize nutrient-dense, high-calorie, and high-protein foods.
   • Chew thoroughly and eat slowly to prevent overeating; limit liquid intake during meals to ½ cup.
   • Consume liquids 1 hour before or after meals, aim for 8-10 glasses daily, and avoid carbonated drinks that cause fullness.
   • Embrace a high-calorie, protein-rich diet with foods like dairy, nuts, meats, and eggs for optimal nutrition.
3. Surviving the Symptoms
   • Manage reflux post-esophageal surgery: Sit up during meals, wear loose clothing, eat 2 hours before bedtime, and elevate the upper body during sleep.
   • Combat nausea: Avoid rich foods, eat moderately, and lie at a 30-degree angle after meals.
   • Handle fullness: Monitor for signs, limit meal sizes, eat slowly, and establish a schedule for smaller, more frequent meals.
   • Take care of diarrhea: Gradually reduce sugar, dairy, and fat; include soluble fiber-rich foods; prioritize food safety.
   • Ease swallowing issues: Choose soft, moist foods and chew thoroughly to aid swallowing.

   Note: Consult with your doctor and clinical dietitian nutritionist for personalized guidance and adjustments.

4. Tips for Caregivers
   • Encourage and provide mental support to the patient.
   • Assist the patient in managing their symptoms and side effects.
   • Coordinate medical appointments and ensure timely medication administration.
   • Help the patient maintain personal care and hygiene.
   • Communicate with empathy and a positive attitude.
   • Assist with household chores.
   • Handle insurance and billing issues on their behalf.