Oesophageal cancer occurs when the cells that make up the lining of the oesophagus (also often referred to as the gullet) change so that they grow more than they should. This can form a lump or a narrowing in the oesophagus that may stop it working normally, causing a degree of blockage. Cancer can also spread and affect the glands or lymph nodes nearby, as well as spreading further to other organs around the body. Oesophageal cancer can cause a variety of symptoms which are explained below.

Image credit: Cancer Research UK Uploader (2016)

Difficulty swallowing

Patients may experience difficulty eating and drinking. The medical term for this is dysphagia. This may vary day-to-day, but usually swallowing will get slowly more difficult as time goes on. Most patients find it harder to swallow solids, often finding bread or meat the most difficult to get down. Some people find that food gets stuck, and they have to wait for it either to go down further into the stomach or they bring it back up.

Heartburn or pain

Patients may experience a burning or achy sensation in the middle of the chest behind their breast bone or in the upper part of the abdomen or tummy. Sometimes this can be severe and people report feeling pain in this area. However, this is a very common symptom in people in general, not just people with oesophageal cancer, with up to 20% of the population suffering indigestion symptoms each week.

Pain on swallowing

Patients may experience pain in the middle of the chest, behind the breast bone, when they swallow food or drink. The medical term for this is odynophagia. In addition some people may get severe pains from spasms of the oesophagus.

Bleeding and anaemia

Cancer in the oesophagus can bleed. Sometimes this bleeding is so slow that it cannot be seen. However, it may cause enough blood loss that a person becomes anaemic. This may cause a feeling of tiredness and lethargy, and a person may get out of breath more easily than normal. In other patients, cancer can cause more noticeable bleeding which may resulting in vomiting up blood, or a patient's stool (or faeces) may turn very dark, smelly and become sticky like tar.

Poor appetite and weight loss

Non-specific but relatively common symptoms of oesophageal cancer include having a poor appetite, not wanting to eat, and unintentionally losing weight.

A number of different tests can be performed to assess people who might have oesophageal cancer, to make the diagnosis and to make further assessments to plan treatment. Our cancer care is provided as part of a regional network. Patients may therefore have different tests in different hospitals. For example, a patient may have an upper GI endosocpy in Weston, a PET-CT scan at Southmead Hospital in Bristol, and an EUS in the Bristol Royal Infirmary. As far as possible, we will minimise the number of trips and travel distances required. However, we also need to make sure we gather the correct information from the different tests available to make the right treatment decision for each patient.

Upper GI endoscopy

The first test for people with difficulty swallowing or problems with heartburn is usually an upper GI endoscopy (often referred to as an OGD). This is a common procedure involving the insertion of a thin tube with a camera on the end through the mouth into the oesophagus, stomach and first part of the small bowel called the duodenum. This test is important to look for oesophageal cancer as well as a range of other problems such as acid damage or non-cancerous narrowing of the oesophagus. It is a routine procedure, but as with any test there are benefits and risks, even though the risks are very low. More information on this procedure, its benefits and risks are available here.

Computed Tomography (CT)

A CT scan is usually the first of a series of specific tests that are done to assess the cancer itself and look for any spread to glands or lymph nodes, and other organs around the body. Having a CT scan involves lying down on a narrow bed which moves through an open ring, like a big doughnut. The scan itself usually takes a few minutes. It involves exposure to x-rays, a form of ionising radiation. Doctors always minimise the amount of radiation to which patients are exposed. For people with oesophageal cancer, the benefits of this test and the information it provides to plan treatment outweigh its risks.

Positron Emission Tomography (PET)-CT

This is a special type of CT. It is another way of looking for spread of cancer to glands or lymph nodes and to other organs. It involves a special injection of a radioactive, sugar-based dye which is combined with a CT scan. The dose of this radioactive dye is very low. The test is very similar to having a normal CT, as described above.

Endoscopic Ultrasound (EUS)

This test is similar to having a standard upper GI endoscopy, as described above, but involves using a slightly different endoscope that has a small ultrasound device at the end of the tube. This procedure is done with a combination of injections (a painkiller and a sedative medication) to help the person relax and allow a careful examination to be performed. The procedure is designed to gain more information about the cancer itself, and it also allows a close look at the glands or lymph nodes near the cancer. If needed, small samples of these nodes can be taken to try and determine if they are affected by spread of cancer.

Staging laparoscopy

This procedure may be performed in selected cases of oesophageal cancer, although it is not necessary for everybody. It is a small operation that is done under a general anaesthetic, using key-hole surgery to have a look inside the tummy or abdomen. It usually requires 3 small incisions. It is performed to look for any evidence of spread of the cancer within the space around the different organs in the abdomen. During the operation, a sample of fluid is often taken to help look for cells that have spread that can only be seen with a microscope, and any abnormal areas that are seen may also be sampled or biopsied. These samples have to be sent off to a laboratory to be examined, which takes 1-2 weeks, so the result is not available straight after the operation. Most people go home the same day. As with any operation, there are some risks which your doctor will explain to you.

Other tests

Occasionally, other tests are required. These may be required to look at specific areas identified by the above tests. For example, the scans may detect an abnormal area on the lower bowel. This may then mean that a telescope examination of the lower bowel is required to know exactly what is going on at the abnormal area. In addition, tests may be required to help assess fitness for treatments. These include tests to examine how well the heart or lungs are working, to know if a person is fit enough to have major surgery. Your doctor will explain any additional tests and why they may be needed.

After having tests to diagnose and assess oesophageal cancer, your doctor will discuss your treatment options with you. Treatment options are determined at a weekly meeting of specialists where all the test results are discussed. A lot of different people are involved in making these decisions, including surgeons, oncologists (cancer specialists), radiologists (imaging specialists), histopathologists (experts in tissue analysis) and cancer nurse specialists. This meeting is called the 'Multi-Disciplinary Team' (MDT) meeting. This means that the right decisions can be made with you based on the specific details of you and your test results.

In general, the treatment options available are explained below.

Curative-intent vs palliative treatment

Depending upon the results of the tests and the individual patient, treatment may be planned to try and remove all cancer and avoid it coming back (curative-intent treatment). Alternatively, it may not be possible to cure the cancer. For example, it may have already spread to other organs, or it may be too big near the heart or main blood vessels. In this case, treatment is called 'palliative', and is designed to give the best combination of quality and amount of time of survival possible. Even when it is not possible to cure a person of cancer, there is much that the team of doctors and nurses can do to help with symptoms and to support a person and their family.

Chemotherapy

Chemotherapy involves the use of different types of drugs to target cancer. Some medicines are given into the vein and others can be taken as tablets. Often a combination is used. Usually treatment is given over a period of months in a series of cycles, with short breaks between to allow recovery. Chemotherapy may be given as part of a curative-intent regime, with other treatments such as surgery or radiotherapy. It may also be given as treatment when it is not possible to cure cancer, to prolong survival or to improve symptoms (palliative chemotherapy). As with any treatment, there are risks and side effects which your doctor will discuss with you.

Radiotherapy

Radiotherapy involves the use of targeted radiation to treat cancer. This is often done as a course of several treatments which therefore require repeated trips to hospital. As with chemotherapy, radiotherapy may form part of a curative-intent treatment plan, or it may be given to help with symptoms when it is not possible to cure a person's cancer (palliative radiotherapy). Your doctor will discuss the details as well as the risks and benefits of treatment.

Surgery

Surgery for oesophageal cancer forms part of a curative-intent treatment plan, most often in combination with chemotherapy (and sometimes radiotherapy) before and/or after the operation itself. The surgery to remove oesophageal cancer is a major operation, involving surgery on both the abdomen and chest. Only about a third of patients diagnosed with oesophageal cancer undergo surgery. Many people cannot have surgery because their cancer has already spread and it cannot be cured. Other reasons surgery is not possible include cancer involving other major organs that cannot be removed (such as the heart), or a patient may not be fit enough to survive the operation itself.

The operation involves removing most of the oesophagus and part of the top of the stomach. The remaining part of the stomach is made into a tube to replace the oesophagus that has been removed. After the operation, once the new tube has healed in place, you can eat normal food, but in smaller amounts, such that many people need to eat 5-6 smaller meals through the day. It can take up to 9-12 months to fully recover from the operation. Your doctor will tell you more about the risks of the operation, the side effects, and the likely recovery period.

Oesophageal stenting

An oesophageal stent is a tube that can be inserted to hold open the oesophagus. This is done using an endoscope, usually with an injection of a painkiller and sedative (not under a full general anaesthetic). It is a good treatment to improve swallowing when a person cannot have curative treatment. Your doctor can explain more about what is involved as well as any risks of the procedure.

Brachytherapy

Brachytherapy is when radiotherapy is delivered directly into a cancer. For patients with oesophageal cancer that cannot be cured, this treatment can be a very good way of helping improve swallowing if the cancer is suitable. It involves having an endoscopy with sedation. This allows placement of the device that delivers the radiotherapy into the oesophagus. Not every cancer is suitable, so your doctor will explain if this is an option for you. We have created an information leaflet about brachytherapy, which is available by clicking here.

Oesophageal cancer affects eating and drinking, so most people will lose some weight. Careful nutrition is a really important part of the management of oesophageal cancer. You may be referred to a dietitian for specialist advice and help managing your nutrition. Some people require specific nutritional supplements, or if they cannot eat and drink enough to maintain their weight, an alternative way of feeding may be considered. Options include placing a thin plastic feeding tube through the skin directly into the bowel in the abdomen (a small operation done under a general anaesthetic) or placing a fine tube through the nose into the stomach or small bowel. If this is necessary, your doctor will explain to you the best option for you and what is involved in more detail.

Here are some useful links to other sources of information and support for patients who have oesophageal cancer. However, as these are external websites, we are not responsible for the accuracy of any content which may change over time.

NHS website:

https://www.nhs.uk/conditions/oesophageal-cancer/

Cancer Research UK:

https://www.cancerresearchuk.org/about-cancer/oesophageal-cancer

Macmillan:

https://www.macmillan.org.uk/information-and-support/oesophageal-gullet-cancer/understanding-cancer/signs-symptoms.html

Oesophageal Patients Association charity:

https://www.opa.org.uk/

GUTSY group - patient support:

http://www.gutsy-group.org.uk/