Unlike cancer of the stomach, a cancer that occurs in an organ with a large volume, esophageal cancers have virtually nowhere to go once they become established, and they usually became evident after it is too late to operate on them. Difficulty swallowing (dysphagia) is the commonest presenting manifestation of cancer of the esophagus. Depending on the size and location of the cancer, the dysphagia usually starts with bulky foods such as meat and later extends to softer foods and liquids. As the tumor enlarges, inability to swallow progresses, and food often is aspirated into the lung. Such aspiration can lead to pneumonia, chocking, and even suffocation or asphyxiation. Because the esophagus is a narrow organ, the growing tumor has little to place to go, and death occurs early, as a result of starvation, suffocation, or aspiration. Treatment of advanced disease rarely provides much relief and may even increase the symptoms of sore throat and difficulty in swallowing.
Fortunately, cancer of the esophagus is rare. It makes up only 4% of all cancers of the gastrointestinal system. So only about 10,000 cases per year are reported in the United States. The disease is much more common in men than in women; fewer than 25% of cases occur in women. It is more common in elderly patients than in younger people, and it occurs in smokers and drinkers more than in nonsmokers and nondrinkers. The combination of smoking and excessive alcohol intake is especially synergistic (additive) in causing cancer of the esophagus. This finding suggests that caustic injury to the esophagus on a regular basis predisposes persons to this disease. In fact, a condition called Barrett’s esophagus, which is caused by chronic reflux (backup) of acid from the stomach to the esophagus, carries a high risk of cancer of the esophagus. Up to 10% of people with this problem develop this type of cancer.
The real goal in the management of this illness is to catch it early enough to operate. The problem is that the disease is not usually respectable (completely removable), and because of the location of esophageal cancers, surgery often is necessary to make the patient’s life bearable. Further, removal of the esophagus is no small chore. A suitable tube must be created to allow swallowing and to keep oral secretion from entering the lung. Therefore, the surgeon must assess the extent of tumor involvement of the wall of the esophagus as well as the size of the primary tumor. This assessment should be made by a thoracic surgeon with the use of both the endoscope and radiographs of the esophagus. Newer surgical techniques have allowed better tolerance of surgery, and death from the operation itself has decreased from more than 30% to less than 5% in the last two decades. Further, the wider use of endoscopy, more of these lesions are detected earlier, and the cure rate has risen from 2 to 3% to around 10 to 15%. Stage of disease, not location within the esophagus, is the only important variable in determining curability.
Chemotherapy and radiation therapy have a relatively high response rate and offer significant opportunity for palliation, although not for survival of cure. Therefore, to pursue a course of treatment is reasonable as long as patient and family understand the side effects and the goals of such treatment, whether chemotherapy alone or combined chemotherapy and radiation therapy.
Dr. Arlene Forestiere, professor of oncology at Johns Hopkins School of Medicine, has designed a program in which patients with early invasive (the tumor has invaded the wall of the esophagus) cancer of the esophagus are subjected to a short but intensive course of combined and concomitant (given together) chemotherapy and radiation therapy before surgery. This neoadjuvant treatment is used to kill potential disease beyond the surgical field before the removal of the esophagus. So far, 40% of patients treated in this fashion have no evidence of cancer at the time of surgery. The ultimate benefit in survival remains to be seen, but for the first time in the history of this disease, a form of treatment has the potential to increase the cure rate, I strongly recommend that my patients participate in this trial if at all possible. If they cannot participate, I offer them the identical therapy at my institution. All physicians who treat cancer of the esophagus are eagerly awaiting the final results of this trials.
After the chemotherapy is given and the patient has healed from the effects of the treatment, a thoracic surgeon removes the esophagus or the portion of the esophagus containing the cancer. A portion of the stomach is pulled up to act as a food pipe, and the patient is then monitored carefully for signs of cancer recurrence. For the first time, I feel some optimism about this illness and I am grateful to Dr. Forestiere.
For patients with esophageal cancer, gentle management of symptoms and careful attention to the side effects must be part of care. One of the most difficult aspects of this management is to prepare patients and their families for the patient’s death. Therefore, physicians should look for this illness if patients have the suggestive symptoms of difficulty in swallowing or intolerance to foods.