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Esophageal Cancer affects 13000 to 14000 people annually. It's incidence has steadily increased over the past 30 years. The American Cancer Society estimates an incidence of about 14,500 in 2006 with 13, 770 deaths. Though 5 year survival rates have been slowly improving over the years, much work still needs to be done to improve the outlook for the most advanced patients.
How advanced your disease at the time of diagnosis has an affect on prognosis. Stage 0 patients ( high grade dysplasia or carcinoma in situ) have 95% 5 yr survival, Stage I patients have up to 80%, Stage IIA up to 40%, Stage IIB 30%, Stage III 15% and Stage IV patients have less than 5% 5 year survival rates. Unfortunately, over 50% of patietns present with the most advanced disease. However, even with such a grim outlook, individual patients with advanced disease do have success in fighting this cancer. It is impossible to know beforehand which patients in these groups will do well. With continuing improvement in surgical and medical treatment for this disease, we hope to increase the number of these individual success stories.
Squamous cell cancer account for about 90% of esophgeal cancers in african american males but only about 50% of caucasian males. It's etiliogy is unclear but the incidence of this particular histology has been decreasing over the past two decades. Risk factors for this type of cancer includes all forms of tobacco including cigaretts, cigars, and chewing tobacco. High intake of alcohol over prolonged period, diets deficinet in fruits and vegetables, history of caustic injury to the esophagus, and history of head and neck cancers or achalasia all seem to have some association with squamous cell cancers fo the esophagus.
Incidence of adenocarcinoma has increaseover the same time period that squamous cell cancers have decreased. Highly associated with adenocarcinoma is a history of heartburn and obesity. In fact, a combination of prolonged heartburn and obesity can increase the relative risk for esophgeal cancer by 180 times. Barrett's esophagus can develop in pateints with prolonged reflux disease. This results in changes to the lining of the esophgaus from a squamous epithelium to a glandular cell type. Over time, they can continue to change and develop what is call 'high grade dysplasia.' Approximately 45% of patients diagnosed with high grade dysplasia have undiagnosed adenocarcinoma of the esophagus. Esophagal cancer at this stage is highly curable with surgical resection; hence, we recommend immediate surgical resection for any patients diagnosed with high grade dysplasia. Waiting to detect cancer in these patients often leads to more advanced disease at the time of surgery and a much poorer prognosis.
Generally there are minimal symptoms in patients with esophageal cancer. Symptoms tend to become evident when the tumor has become large and advanced. Some typical presenting symptoms are listed below.
Making a diagnosis of esophageal cancer requires a biopsy of tissue. We employ several studies that helps us diagnose the disease as well as examine the extent of disease. Some of these studies are listed below.
Chemotherapy is often used either before or after surgery or alone in the most advanced cases of cancer. Chemotherapy is given before surgery in locally advanced cancer that may or may not involve the local lymph nodes. It's design is to shrink the tumor burden in the hopes of making the tumor a resectable lesion and is often used in conjunction with radiation. It is a systemic treatment in order to address any microscopic tumor cells in the body, including lymph node disease.
Common chemotherapuetic regimens include cisplatin and 5-FU which is given in 4 monthly cycles or 5-FU and mitomycin which is given in 2 monthly cycles. Other medications include irinotecan or paclitaxel. Medications are given on an outpatient basis and can be given at your local institution. May of these drugs are used as part of a clinical trial, and hence you shuld consult with your thoracic surgeon or oncologist.
Radiation is the use of high energy beams to cause damage to cells. This is often used in conjunction with chemotherapy in the pre-operative setting to shrink the tumor. Both normal and cancer cells are dmaged by radiation; hence, efforts are made to provide the highest amount of radiation to the tumor which minimizing to radiation to normal tissue. Treatment with radiation often requires planning with CT scans and simulators to accurately map out the treament area. Tattoos are placed on the skin to mark the area of interest. When treatment begins, you will not need any additonal preparation. The treatment only takes a few minutes, but the process requires daily treatments for up to 5 weeks.
Surgery is the most common treatmetn for esophageal cancer. It's goal it to complete remove the cancer and all surround lymph nodes. Surgery is most effective with earlt disease, but can be used in conjunction with chemotherapy and radiation for advanced cancer. The goal is to not only remove the disease, but provide relief of symptoms such as obstruction and dysphagia. A key compenet of surgery is reconstruction of a new esophagus replacement.
There are several type of surgery for esophageal cancer. What us best for you will depend on your cancer, the type, location, extent of disease, as well as your health and overall condition. Common surgical options include transhiatal esophagectomy, three hole esophagectomy, Ivor-Lewis esophagectomy, thoracoabdminal esophagectomy, and minimally invasive esophagectomy. All involve removing the esophagus and reconstructing it with the stomach, but incertain cases the colon or small bowel may be used as an esophageal replacement. A feeding tube is placed during surgery to support your nutrition until you can eat adequately.
Most patients with stay in the hospital for 10-14 days following surgery which includes a stay in the ICU. Pain will be controlled with a patient controlled anesthesia or PCA, an epidural catheter, or some combination of both. The main goal after surgery is pain control and early mobilization. Coughing, deep breathing, and walking activity are encouraged and supported. A barium swallow will be performed about a week after surgery, and if no leak is found, an oral diet is started.
Since the stomach is now tubularized, the volume of food intake will be less per sitting. Hence, the dietary lifestyle is often changed to taking in 6 small meals per day as opposed to 3 large ones. With time, the stomach may distend somewhat to allow for greater volume in one sitting, but this takes time. Once discharged from the hospital, your diet may still be supported by tube feeds at night until your oral intake increases. Physical activity and exercise are required following discharge and should slowly be increased following your physican's guidelines. Depending on the type of surgery you received, you may be on pain medication at home for up to several weeks.
Key points to remember are the following:
Esophageal resection is one of the most stressful operations for the body. Complications and mortality rates can be high; hence, it is important to be treated at experienced centers. Dedicated surgeons, anesthesiologists, and nurses are critical to minimizing a patient's risk. Inexperienced centers can have a mortality of up to 25%. In experienced centers, that rate drops to about 5 to 8%. The most common complications include anastomic leak, chylothorax, pneumonia, respiratory failure, heart arrhythmias, heart attacks, and vocal cord injuries resulting in hoarse or difficulty swallowing.
Common side effect as a result of surgery include dysphagia which may be due to stricture formation at the anastamosis or connection between the esophagus and stomach. Often a simple dilation can help relieve these symptoms. Dumping syndrome can results which may include flushing, palpitations, dizziness, sweating, cramping, or diahhrea following meals. This may be addresss with diet modification. Reflux of stoamch contents or bile can also occure due to the loss of the valve at the GE junction. Head position and diet modification can assist in addressing this symptom.
Following treatment with surgery, chemotherapy, and/or radiation, you will require lifelong follow-up with your thoracic surgeon. Cancer can bring continued physical, psychological, emotional, and financial burdens on patients. Recurrence of cancer is always a concern. Periodic asessment by your surgeon and oncologist may require CT scans or PET scans at regular intervals.
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©2007, Division of Thoracic Surgery at Brigham and Women's Hospital. All rights reserved.
Division of Thoracic Surgery
Brigham and Women's Hospital
75 Francis Street
Boston, MA 02115
Phone: (617) 732-6824