Medical advice

What are the symptoms?

Oesophageal cancer may cause no symptoms until it begins to obstruct passage of food and fluids down the gullet, or to make swallowing painful (dysphagia). As the cancer develops, there is progressive difficulty in swallowing, at first with solids such as meat and bread, and then with softer foods, and eventually there is difficulty in getting liquids down. Patients begin to lose weight and may have other symptoms, such as choking, coughing, unexplained chest infections or a hoarse voice. Although some patients report long-standing heartburn before developing these symptoms, most people who develop oesophageal cancer have no symptoms of this kind before they experience dysphagia.

How is the diagnosis made?

Most patients seek medical attention because of dysphagia, and going to the doctor early when symptoms begin is important, to increase the chances of early diagnosis and effective treatment. The GP is likely to make a referral to a specialist for investigations. These are likely to include a barium swallow, which involves swallowing a white liquid containing barium, which shows up on X-ray, outlining the oesophagus and revealing any obstruction. Another test likely to be used is an endoscopy, in which a narrow, flexible telescope is passed gently into the gullet through the mouth, using a local anaesthetic throat spray. Changes in the lining of the gullet can be seen and samples taken (biopsy) for laboratory examination.

If cancer is diagnosed, other tests may be needed to see if it has spread. These include chest X-ray and ultrasound examinations of the chest, and other tests such as a CT scan or magnetic resonance imaging (MRI) scan. Sometimes it is necessary for a surgeon to look inside the abdomen using a special illuminated tube (laparoscopy). 

Treatment

Surgery is the most commonly used treatment in the United Kingdom, particularly if the cancer has not spread beyond the oesophagus. Depending on the position of the tumour the surgeon may need to enter the chest cavity, the abdomen or the neck, and will remove the affected part of the oesophagus with the surrounding lymph glands. A tube is then made out of the stomach, which is drawn up into the chest or neck where it is joined to the remainder of the oesophagus. Patients are usually cared for in an intensive care ward after this operation and after leaving hospital are able to eat normally, although may feel full rather quickly. This sensation usually improves over the next few months.

Sometimes dysphagia (as mentioned earlier in the leaflet) returns weeks or months after the operation. This may be because the cancer has recurred, but often is due to scarring (a ‘stricture’) where the surgeon has made the join. These strictures can be easily stretched using an endoscope.

Radiotherapy also offers a potential cure, and it is particularly useful for people with early tumours, especially squamous cancer. Radiotherapy can be used in conjunction with surgery and is also often used as an alternative to surgical treatment, when the type and position of the tumour and the patient’s general condition may influence the decision to operate. When radiotherapy is given in an attempt to cure the cancer it is known as radical radiotherapy or, when the tumour cannot safely be removed by surgery, radiotherapy, sometimes with chemotherapy, is used in smaller doses and is known is palliative radiotherapy, intended to treat the symptoms caused by the cancer. Radiotherapy can be given as an external beam or on the inside of the gullet via an endoscope (brachytherapy).

Treatment of symptoms

If surgery is not possible, there are other ways to help to relieve difficulties in swallowing.

Endoscopic intubation is usually done under sedation or anaesthetic in the endoscopy department. A tube is inserted into the gullet to keep it open, so that food and fluid can be swallowed without difficulty. These tubes are made of either plastic or springy metal coils. They can become blocked by large food particles so that specific instructions on diet are always provided. Sometimes these tubes cause troublesome heartburn and regurgitation, which can be helped considerably by taking acid suppressing medication.

Endoscopic laser treatment is also possible, and a specialist endoscopist will use a laser to destroy any tumour that is growing into the gullet. In some patients laser treatment and intubation need to be combined.