Esophageal Cancer
Esophageal cancer, the eighth most reported cancer globally, poses a significant health concern, particularly in the Northeast region of India, where the highest incidence is reported, contributing to its recognition as ‘Esophageal Cancer Belt.’ This geographical zone extends from Northeast China to the Middle East, where the prevalence of this type of cancer is notably high.
This condition predominantly affects males more than females, and according to a study conducted by the Indian Council of Medical Research (ICMR), the age-standardized incidence rate (ASR) in India is 6.5 per 100,000 males and 4.2 per 100,000 females. The study further highlights that there are approximately 47,000 new cases and 42,000 fatalities attributed to esophageal cancer each year in India.
The unique challenges posed by esophageal cancer and its treatment contribute to a state of dilemma for patients. The esophagus plays a crucial role in the digestive system, acting as a conduit for the passage of food to the stomach. The impact of esophageal cancer and its treatment on this vital function can significantly affect the patient’s overall well-being and quality of life.
The article invites readers to delve deeper into the complexities of esophageal cancer, exploring its causes, risk factors, and potential treatment options.
What is esophageal cancer?
Esophageal cancer is characterized by the uncontrolled division of cells within the esophagus, leading to the formation of an abnormal mass of tissue known as a tumour. The esophagus is a vital hollow, muscular organ situated in the chest region called the mediastinum. Serving as the food pipe, it connects the throat to the stomach and plays a crucial role in the digestive process by facilitating the passage of food and liquids into the stomach.
Positioned near the trachea, or windpipe, the esophagus is protected by a small structure called the epiglottis, which acts as a flap to prevent food from entering the lungs during swallowing.
In the context of esophageal cancer, the malignant cells that develop within the esophagus can disrupt the normal functioning of the tissue. Furthermore, these cancerous cells have the potential to metastasize or spread to other distant sites within the body. Common sites for metastasis in esophageal cancer include the lungs, liver, and stomach. This process involves cancer cells breaking away from the original tumour, entering the bloodstream or lymphatic system, and establishing new tumours in distant organs or tissues.
Understanding the anatomy and function of the esophagus, as well as the potential consequences of cancerous growth, is essential in developing effective strategies for detecting, managing, and treating esophageal cancer.
What are the different types of esophageal cancer?
The esophagus is a complex organ composed of distinct layers, each with its specific structure and function. These layers are crucial for the normal functioning of the esophagus in facilitating the transport of food from the mouth to the stomach. The layers of the esophagus include the mucosa, submucosa, muscularis propria, and adventitia.
- Mucosa: This innermost layer lines the esophagus and consists of several sub-layers, including:
- Epithelium: This is the innermost layer of the mucosa, comprising flat, thin cells known as squamous cells. These cells form a protective barrier and are the first point of contact for ingested food.
- Lamina propria: Positioned between the epithelium and the muscularis mucosa, this layer is composed of connective tissue. It provides support and nourishment to the epithelium.
- Muscularis mucosa: This muscular layer is located beneath the lamina propria. Although relatively thin, it plays a role in the movements of the mucosal layer.
Types of Esophageal Cancer
Esophageal cancer is classified into different types based on the type of cells in which it originates. The three main types are:
- Squamous Cell Carcinoma (SCC): Characterized by abnormal growth in the squamous cells of the esophageal mucosa, SCC is the most common type of esophageal cancer reported in certain regions such as Asia, Africa, and Eastern European countries.
- Adenocarcinoma: This type of cancer originates in the glandular or mucous-producing cells of the esophagus. It is often found in the lower thoracic or lower third portion of the esophagus and is associated with conditions like Barrett’s esophagus, where glandular cells replace squamous cells.
- Small Cell Carcinoma: A rare form of esophageal cancer, small cell carcinoma originates in neuroendocrine cells, which release hormones into the bloodstream in response to nerve signals.
Other Rare Types
In addition to the main types mentioned above, lymphoma and sarcoma of the esophagus are also reported, although they represent less than 1% of esophageal cancer cases. Understanding the different layers of the esophagus and the specific types of esophageal cancer is crucial for accurate diagnosis, treatment planning, and improving outcomes for individuals affected by this disease.
What are the different signs and symptoms of esophageal cancer?
Recognizing all the signs is crucial for early detection and prompt medical intervention. Here’s an elaboration on each symptom:
1. Difficulty swallowing: Esophageal cancer can lead to a narrowing of the esophagus, making it difficult for food and liquids to pass through.
2. Pain: Discomfort or pain during swallowing behind the breast, under the throat or collar bone region, especially when consuming solid foods, may be indicative of esophageal obstruction caused by the cancerous growth.
3. Chest pain: Chest pain may vary in intensity and can be persistent or intermittent.
4. Burning-like sensation in the chest region: Symptoms of heartburn or gastroesophageal reflux disease (GERD) may show up in the chest region.
5. Indigestion: Discomfort or pain in the upper abdomen may be a symptom of esophageal cancer.
6. Nausea & Vomiting: These symptoms may be more prominent after eating.
7. Unusual or Unexplained Weight Loss: Symptoms that may indicate various underlying health issues, including esophageal cancer.
8. Nagging Cough: A persistent cough that doesn’t seem to be related to respiratory issues may be associated with cancer.
9. Hoarseness: Occur due to the involvement of the esophagus and adjacent structures.
Individuals experiencing these symptoms, especially if they are persistent or worsening, should seek prompt medical attention.
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What are the different stages of esophageal cancer?
Staging is a process where the cancer’s severity is measured based on it’s location, size, and spread of the tumour. Staging is crucial because it helps in determining the patient’s prognosis and treatment plan. The cancer is staged based on the American Joint Committee on Cancer or AJCC’s TNM system. TNM staging system focuses on the size of the cancerous tumour, the number of lymph nodes (N) it has spread to, and whether it has metastasised or showed in sites away from it’s point of origin (M).
Based on the above-mentioned criteria, esophageal cancer is divided into five stages, and they are as follows;
- Stage 0: The cancerous cells are found only on the top lining of the esophagus.
- Stage 1: The cancerous tumour is relatively small and localised.
- Stage 2: The cancerous tumour has spread through the muscle but has not shown up in nearby blood vessels, lymph nodes or organs.
- Stage 3: The cancer has spread to nearby lymph nodes or tissues.
- Stage 4: The cancer has shown up in distant sites.
What are the different grades of esophageal cancer?
The tumour grade describes how similar or different a cancerous tumour looks when compared to a normal cell by looking at the sample under a microscope. At the same time, it gives insight into how fast the tumour divides and grows.
- Grade 1: Also known as a low-grade tumour, it describes the cancerous cells that look similar to the normal and are growing slowly.
- Grade 2: Also known as an intermediate tumour, it describes cancer that looks somewhat different from normal cells and grows quicker than normal.
- Grade 3: Also known as a high-grade tumour, it describes tumours that are dividing aggressively and look extremely different when compared to normal cells.
Other than the above-mentioned grades, cancerous cells whose grading cannot be determined are referred to as GX or undetermined grades.
Read: The Fight Against Colorectal Cancer: Why It Is Essential To Remove Colon Polyps
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How is esophageal cancer diagnosed?
This imaging test involves the patient swallowing a barium liquid. Barium coats the esophageal surface, highlighting any abnormal structural changes. A series of X-rays are then taken to visualize the esophagus and detect any anomalies.
In this procedure, the upper lining of the esophagus is examined using an endoscope, a thin, flexible tube with a light and video camera. The patient is typically given anaesthesia, and the endoscope is passed down the throat. Additionally, an inflatable balloon may be used to stretch the esophagus for a clearer view.
Ultrasound imaging utilizes sound waves to create images of the esophageal wall. Endoscopic ultrasound, a specific type of ultrasound, involves inserting an endoscopic probe with an attached ultrasound into the esophagus for a detailed examination.
Similar to EGD, bronchoscopy involves the insertion of a thin, flexible tube with a light into the mouth or nose. However, bronchoscopy specifically examines the airways and may be performed to assess the involvement of nearby structures.
A CT scan uses X-ray images taken from different angles to create a three-dimensional image of the body. This imaging technique helps evaluate the size and extent of the tumour and detect any potential spread to nearby structures or lymph nodes. PET-CT is an advanced imaging test that involves the use of radioactive sugar substances. The radioactive emissions create detailed images of the internal structures of the body, helping to identify areas with increased metabolic activity, which is often indicative of cancer.
MRI employs magnetic waves to produce detailed images of the body. It is particularly useful in assessing soft tissues and can provide additional information about the tumour’s characteristics and extent.
Other methods used for breast cancer investigation
Once imaging tests reveal suspicious areas, a biopsy is performed to obtain tissue samples for laboratory analysis. The biopsy confirms whether the tumour is benign or malignant, identifies the type of cancer, and guides treatment decisions. This comprehensive diagnostic approach enables healthcare professionals to make informed decisions regarding the management and treatment of esophageal cancer.
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What are the various esophageal cancer treatment methods?
Surgery: Surgery has been the most commonly recommended treatment for esophageal cancer. It depends on the size and location of the tumour. In most cases, the surgery is done without undergoing neoadjuvant chemotherapy or radiation (the process where chemo drugs or radiation is given to reduce the size of the tumour). However, patients with a locally advanced tumour have to undergo chemotherapy to reduce the size of the tumour.
Esophagectomy is the most common surgical procedure performed on esophageal cancer patients. It is a process where the portion of the esophagus, affected by cancer is removed, and the healthy portion is connected to the stomach. Sometimes, the medical expert has to remove the whole esophagus structure and replace it with a portion of the intestine or artificial esophagus.
Otherwise, the expert inserts a feeding tube called percutaneous endoscopic transgastric jejunostomy or PEJ, which carries food items directly to the stomach or intestine. In severe cases, the doctor performs surgery to reduce the severity of the symptoms or to help people eat better, called palliative surgery.
Endoscopic therapy: It involves the long flexible structure called the endoscope to treat the symptoms and side effects associated with esophageal cancer.
- Endoscopy and dilation: It is a process where the esophagus is expanded depending on the tumour’s growth.
- Endoscopy with stent placement: A metallic structure called a stent is inserted into the esophagus to keep it expanded.
- Electrocoagulation: It is a type of palliative treatment where the cancerous cells are destroyed by applying heat to them. It is usually adopted to remove a blockage caused by the tumour.
- Cryotherapy: It is also the treatment process where the tumour tissue is removed to help the patient swallow easily.
Radiation therapy: It is a treatment process where high-energy X-rays are used to target and destroy the tumour cells. External-beam radiation therapy is the most common form of radiation therapy used to treat esophageal cancer, where a machine outside the body provides the radiation.
Chemotherapy: It is a treatment process where powerful drugs are administered into the human body to target and destroy the cancerous cells. Chemotherapy helps in reducing the size of the tumour and to prevent the cells from dividing further. Chemotherapy is given both before treatment (to reduce the tumour) and after surgery (to reduce the cells in the bloodstream).
Other treatment options like targeted therapy and immunotherapy are available for patients.
What are the different side effects of esophageal cancer treatment?
Esophageal cancer treatments, including surgical methods, can have various side effects that may significantly impact a patient’s quality of life. It’s important for individuals undergoing treatment to be aware of potential side effects and work closely with their healthcare team to manage these challenges effectively. Here’s an elaboration on the common side effects associated with esophageal cancer treatment:
– Difficulty in eating normally: Surgical methods, such as esophagectomy, may lead to challenges in swallowing or the absence of a functional esophagus, making it difficult for patients to eat normally. Dietary adjustments and support from healthcare professionals may be necessary.
– Fatigue: Cancer treatments, including surgery, radiation therapy, and chemotherapy, can cause fatigue, a persistent feeling of tiredness or weakness that may affect daily activities.
– Sores: Radiation and chemotherapy can cause irritation to the mucous membranes in the mouth and throat, leading to the development of sores and discomfort.
– Nausea and Vomiting: Chemotherapy and certain other treatments may trigger nausea and vomiting, impacting a patient’s overall well-being.
– Hair Loss: Some cancer treatments, particularly certain chemotherapy drugs, can lead to temporary or permanent hair loss.
– Cough and Hoarseness: Irritation to the respiratory tract, either from the cancer itself or as a side effect of treatment, can result in coughing and hoarseness.
– Reddening: Changes in skin pigmentation, such as reddening or darkening, may occur as a reaction to radiation therapy.
– Loss of Taste: Changes in taste perception, known as dysgeusia, can occur during cancer treatment, affecting the way foods and beverages taste.
– Bruising, Bleeding Gums, or Nosebleeds: Certain treatments may impact blood clotting and lead to bruising or bleeding issues.
– Breathlessness and Looking Pale: Anaemia, a condition characterized by a low red blood cell count, can result in breathlessness and a pale appearance.
– Frequent Infection: Weakened immune function due to cancer treatments can make patients more susceptible to infections.
– Loss of Appetite: Cancer and its treatments can affect appetite, leading to a decreased desire to eat.
– Skin Sensitivity to Sunlight: Some treatments may make the skin more sensitive to sunlight, requiring patients to take precautions to avoid sun exposure.
– Changes in Bladder or Bowel Habits: Treatment effects on the digestive system may lead to changes in bowel habits.
– Sexual Dysfunction: Cancer treatments can impact sexual function, causing issues such as erectile dysfunction or changes in libido.
– Neuropathy: Neuropathy involves nerve damage and can result in symptoms like tingling, numbness, or pain in the hands and feet.
Patients are encouraged to communicate openly with their healthcare team about any side effects they experience. Supportive care, including medications, lifestyle modifications, and counselling, can help manage these side effects and improve the overall quality of life during and after esophageal cancer treatment.
What are supportive therapies for esophageal cancer?
People who have undergone radical treatment processes will have to undergo supportive therapies to ensure a better quality of life.
– Feeding tube: Esophageal cancer patients may have to undergo radical surgical processes that remove a portion of the esophagus. So, patients may require a J-tube placed in the abdomen for direct liquid nutrition into the small intestine, preventing further weight loss and enhancing treatment tolerance. Treatments like chemo and radiation can cause painful mouth and throat sores, exacerbating nutrition issues.
– Esophageal dilation: This procedure involves stretching a narrowed or blocked esophageal area for improved swallowing. A balloon or pipe-like device is passed down the throat to stretch the narrowed section, with the option for repetition. Before the procedure, a sedative may be given, and the throat may be numbed. Risks include bleeding or perforation, requiring surgery.
– Esophageal stent: An esophageal stent is a device used to maintain the openness of the esophagus, commonly employed in treating narrowing or blockages. Typically made of metal or silicone, this tubular structure provides structural support. Inserted into the esophagus, it helps alleviate swallowing difficulties and related symptoms.
– Argon Plasma Coagulation (APC): This medical procedure uses argon gas in a colonoscopy or upper endoscopy to control bleeding from specific lesions in the gastrointestinal tract. Argon gas serves as an alternative to cauterization or laser treatment for stopping internal bleeding.
– Diet and nutrition: For individuals with esophageal cancer, adhering to a regular diet poses significant challenges due to the impact of the disease on the digestive system. Swallowing difficulties, often caused by narrowing or blockage of the esophagus, can make the normal process of food consumption extremely challenging for these patients. As a result, more liquid diet and nutrition formulas are used.
– Emotional health issues: Positive mental health helps individuals cope with stress, navigate emotional challenges, and find satisfaction amidst cancer-related difficulties. This support reduces anxiety and depression, fostering a positive outlook.
– Pain management: Beyond alleviating suffering and enhancing the quality of life for individuals, proper pain management supports overall recovery and promotes physical and mental well-being. Uncontrolled pain can hinder a patient’s ability to engage in daily activities, impede rehabilitation efforts, and lead to increased stress and anxiety. Patients can opt for Ayurveda, ozone therapy, Chinese medicine and more for the same.
What are the important follow-up care steps after esophageal cancer treatment?
Continued monitoring is crucial for esophageal cancer survivors to prevent the return of the disease. A healthcare specialist outlines the frequency of required physical examinations and blood tests for individuals who have undergone esophageal cancer treatment. The oncologist conducts regular screenings to detect any signs of cancer recurrence or the emergence of secondary cancers. In addition to scheduled check-ups, patients are encouraged to maintain comprehensive health records to facilitate smooth follow-up care. Physicians actively monitor routine blood work to identify any indications of esophageal cancer reappearance.
In conclusion
A multidisciplinary strategy encompassing early identification, efficient treatment choices, and comprehensive patient care is necessary to comprehend and manage esophageal cancer. Even while there is still a long way to go, improvements in medical research and the continued focus on increasing awareness give those impacted by the disease hope for better outcomes and a brighter future. By raising awareness, supporting early intervention, and adopting a holistic approach to treatment, we may go one step closer to a future in which the effects of the condition are reduced and the road to recovery is characterised by resiliency, encouragement, and a rekindled sense of hope.
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