Oesophageal Cancer

Oesophagus is a muscular tube that connects the mouth to the stomach. Its also commonly called the food pipe. Oesophageal cancer is the 6th most common cancer in India and is also the 6th most common cause of cancer-related deaths in India. In 2018 there were 52,396 new cases and 46,504 deaths in India due to Oesophageal cancer. 

TYPES AND SUBTYPES

Oesophageal cancer may be classified based on cell type:  Squamous cell carcinoma (originates from squamous cells that line the oesophagus and is found in the upper and middle part of the oesophagus) or Adenocarcinoma (originates from the glandular tissue in the lower part of the oesophagus).

STAGING OF OESOPHAGEAL CANCER

If you are diagnosed with cancer, your doctor will run more tests to determine the extent (stage) of your cancer. Your cancer's stage is an important input in deciding on your treatment. The stage of a cancer describes the size of the cancer and how far it has spread. It may be described as stage 0 to stage IV and takes into account: the size of the cancer, whether the lymph nodes are affected, if the cancer has spread to other parts of the body.

• • Stage 0 (carcinoma in situ): The tumour involves only the uppermost layer and under the microscope.
  • Stage I: The tumour invades deeper into the wall of the oesophageal with no spread of to the lymph nodes, or other parts of the body. Stage IA involves the upper and second layer of the oesophagus. Stage IB involves the third layer of the oesophagus, the muscular layer.
  • Stage II: Consists of two sub-stages. Stage IIA, the tumour invades the deepest layer of the oesophageal with no spread of the tumour to lymph nodes. Stage IIB, the tumour invades the first and second layer of the oesophagus and has spread to 1 or 2 nearby lymph nodes.
  • Stage III: Consists of three sub-stages. Stage IIIA, the tumour invades the sac around the lungs or heart with no spread to lymph nodes OR the tumour invades the outermost layer of the oesophagus and 1 or 2 nearby lymph nodes OR The tumour invades three of four oesophageal layers and 3 to 6 regional lymph nodes. Stage IIIB, the tumour invades the outermost layer and 3 to 6 lymph node. Stage IIIC, the tumour invades the sac around the lungs or heart and 1 to 6 lymph nodes are affected OR The tumour invades nearby tissues including bones of the spine or the airway OR has spread to 6 or more lymph nodes.
  • Stage IV: The tumour has spread to other parts of the body.

Sources: Cancer India; Cancer.Net; Cancer.org; European Society of Medical Oncology (ESMO)

DIAGNOSTIC TESTS IN OESOPHAGEAL CANCER

• • Clinical history: A clinician may ask you for symptoms such as difficulty and pain while swallowing, choking, indigestion, heartburn, vomiting, unexplained weight loss, coughing and pain in the chest or throat.
  • Barium swallow: An x-ray is taken after the patient swallows a liquid containing barium which coats the surface of the oesophagus. This contrast agent makes the tumour easier to visualise and allows the radiologist to discern details about the tumour that cannot be seen on a normal X-ray.
  • Endoscopy (Oesophagus-gastric-duodenoscopy, or EGD): A thin, flexible tube with a video camera is passed down the throat and into the oesophagus while the patient is sedated. If there is an abnormality seen, an endoscopic biopsy sample will be taken and sent to the pathology lab.
  • Endoscopic ultrasound: This procedure is usually done along with the endoscopy. An endoscopic probe with an attached ultrasound is inserted into the oesophagus through the mouth to gather more details about the tumour and the lymph nodes.
  • Bronchoscopy: This test is similar to the endoscopy, wherein a thin, flexible tube with a light on the end is passed into the windpipe. It helps clinicians detect if the tumour is growing into the person’s airway.
  • Biopsy. A biopsy can help the clinical team make a definitive diagnosis of oesophageal cancer. A small amount of tissue is removed and analysed by a pathologist. The pathologist can provide details on the characteristics and behaviour of the cancer cells that can help choose the best path of management.
  • Molecular testing; Laboratory tests can be done to identify specific genes and proteins in tumour cells to determine treatment options. Terms one might hear include PD-L1 and microsatellite instability (MSI) testing and HER2 testing.
  • Radiological tests: Computed tomography (CT or CAT) scan: CT scans can be used to measure the tumour size and help in staging. Sometimes a special dye may be used for better visualisation and is also useful to detect spread of the cancer. Magnetic resonance imaging (MRI): MRI scans can be used to measure the tumour size for staging and is also useful to detect the spread of the cancer. Positron emission tomography (PET) scan: A PET scan creates pictures of organs and tissues inside the body to detect the spread of cancer to distant organs. A small amount of a radioactive sugar substance is injected into the vein which is absorbed by cells that use the most energy (including cancer cells).

TREATMENTS

The management of cancer depends on various factors, including the stage of the cancer, additional health issues, age etc. Surgery, radiation or chemotherapy may be used.

• • Surgery: The surgeon focuses on the removal of the tumour and a margin of surrounding healthy tissue. Surgery may be performed laparoscopically – a minimally invasive method of surgery. This is traditionally the most common treatment for oesophageal cancer but is useful mainly for patients with early-stage oesophageal cancer. In advanced oesophageal cancer, a combination of chemotherapy and radiation therapy may be used before surgery. This is done to shrink the tumour. Sometimes surgery is used to shrink the tumour in advanced cases in whom the entire surgery cannot be removed and is leading to symptoms. Side effects: Surgery of the Oesophagus carries a high risk of side effects including the leakage of food through the anastomosis into the chest, difficulty swallowing, vomiting nausea, heartburn etc.
  • Endoscopic therapy: These are mostly palliative therapies in advanced disease. A number of procedures may be considered: Endoscopy and dilation (expands the Oesophagus and has to be repeated if the tumour grows) Endoscopy with stent placement (An Oesophageal stent is a metal, mesh device placed endoscopically to keep the Oesophagus open when the tumour leads to obstruction) Electrocoagulation (It is a form of palliative treatment that kills cancer cells with an electric current) Cryotherapy (It is a form of palliative treatment that uses a probe that can freeze and remove tumour tissue).
  • Radiation therapy: Radiation therapy uses high-energy particles to destroy cancer cells. A radiotherapy regimen consists of a specific number of treatments over a period of time. The most common type of radiation treatment is called external-beam radiation therapy, which is given via a machine outside the body. Side effects: fatigue, skin irritation, diarrhoea, blood in urine or semen, loss of hair, etc.
  • Chemotherapy: It is the use of drugs to kill tumour cells or limit their growth. In some patients, it is administered before surgery to reduce the size of the tumour and make its removal easier during surgery. This strategy is called neo-adjuvant chemotherapy. Chemotherapy and chemoradiotherapy can also be administered after surgery to clear tumour cells that may remain. Side effects: This depends on the agent used but common side effects include hair loss, nausea , vomiting, diarrhoea, mouth ulcers, anaemia, higher risk of bleeding, lowered immunity, kidney damage, heart damage.
  • Targeted therapy: Targeted therapy blocks specific genes or proteins, to reduce the growth and survival of cancer cells. These may be HER2-targeted therapy which targets tumours in which the HER-2 gene is overactive and anti-angiogenesis therapy which focuses on the blood vessel development within the tumour. Side effects: These depend on the agent used but may include chills, fever, diarrhoea, wheezing, headache, fatigue etc.
  • Immunotherapy (biologic therapy): This therapy boosts the body's immune system against cancer cells. Side effects depend on the agent used.
  • Palliative care: Palliative care focuses on reducing the symptoms and improving quality of life of the patients. Studies have reported that people who receive palliative care along with treatment tend to have less severe symptoms, a better quality of life, and more satisfaction with their care.

Sources: Cancer.Net; European Society of Medical Oncology (ESMO)

MULTI-DISCIPLINARY TEAM (MDT): Unlike most other diseases, cancer treatment requires an integrated approach from several specialists, each with their own expertise. This team of specialists who would work together on your cancer, is referred to as the Multi-Disciplinary Team (MDT). Many global organisations have recognized the importance of a MDT for cancer treatment, as it improves coordinated care to you, as a patient. Your MDT would include specialists from the following:

• • • Gastroenterologist: A specialist who deals with conditions of the digestive tract. Performs the endoscopic tests for Oesophageal cancer
    • Thoracic Surgeon: A surgeon who specialises in operating on diseases in the chest region
    • Medical Oncologist: Specialist that decides the optimum course and agent for chemotherapy
    • Radiologist: A specialist who interprets MRI, X-rays and CT scans
    • Pathologist: A specialist who studies tissues under the microscope and provides insights regarding cancer cells that help decide treatment
    • Radiation Oncologist: A specialist that decides the optimum course and agent for radiotherapy
    • Palliative care specialist: A specialist that helps patients deal with the physical and psychological symptoms involved with the diagnosis and management of oral cancer
    • Nutritionist: This professional creates specialised nutrition plans for patients, especially important when a feeding tube is used post-operatively.

Some hospitals that take an organ-based approach to cancer, have a separate department for Gastrointestinal Cancers. These teams comprise of specialists who have dedicated training in cancers of the digestive system.

TUMOR BOARD: A tumor board is a meeting where your Multi-Disciplinary Team discusses cancer cases and shares knowledge. The board’s goal is to determine the best possible cancer treatment and care plan for an individual patient. Having fresh perspectives from other doctors makes it much easier to come up with that plan.

In some hospitals, all cancer cases are discussed at the Tumor Board, while in other hospitals the Tumor Board focuses on cases where a doctor seeks inputs from other specialists on the patient’s case. It’s OK to ask your doctor if or why your case was discussed at a tumor board. Or if it wasn’t, why not? In some cases, a patient’s treatment plan is very straightforward using standard treatment guidelines, and the doctor may feel a tumor board review isn’t needed. However, you can request that one be done.

SUPPORT GROUPS: These are offline or online groups that connect patients suffering from cancer. Do find out about a support group around you. The hospital where you are being treated may have a support group that you could join.

Sources: Mayo Clinic

Choosing your oncologist and hospital is a very important decision, we recommend you make the time to research your options. We profile hospitals and doctors based on the range of services they offer for Oesophageal cancer treatment, use our search tools to help you find a suitable medical provider. You may call us for any assistance while selecting or booking. 

If you’ve been diagnosed with cancer, you need to find an oncologist to begin your treatment. An oncologist is a doctor who specializes in treating cancer. For oesophageal cancer, you can start by visiting a surgical oncologist or a gastrointestinal surgical oncologist. Choose someone you are not only confident about but also comfortable with.

TIPS TO FIND AN ONCOLOGIST

1. 1. Look for Specialists: Look for doctors who treat your specific type of cancer - oesophageal cancer or digestive tract cancers. You may need to work with more than one type of oncologists – surgical, medical or radiation oncologists.
   2. Gather Feedback: Discuss with friends and family, especially those who’ve taken similar treatment before. Online communities are a quick way to get feedback from others who’ve experienced your type of cancer before.
   3. Check the doctor’s credentials: Find out if the doctor has received any advanced training. There may be super-specialists available for gastrointestinal cancers, who have received dedicated training on treating oesophageal If doctor’s credentials are not available easily, you have the right to ask for it from the doctor directly.
   4. Review doctor’s experience: Check how long the doctor has been practicing after completion of formal oncology education. How many patients with your type of cancer – oesophageal cancer – does the doctor see every year? In case of surgeons, studies have proven that higher volumes of surgeries lead to better outcomes. Organ-specific surgeons are also available in some hospitals, they have advance training and experience in operating cancers in specific organs.
   5. Find out hospital affiliations: Which hospitals does the doctor practice in? The availability of a multiple types of doctors at the hospital where you get treated is important. Find out what support staff is available at the hospital e.g. dietitian, counselor, home healthcare facilities etc.

TIPS TO FIND A HOSPITAL

1. 1. Lookout for hospitals with lot of experts: Look for hospitals that offer a multi-disciplinary approach to gastrointestinal cancer treatment. This means each you receive inputs from many cancer experts. You will be helped by specialists including surgeons, medical oncologists, radiation oncologists, oncology nurses and other supporting staff. Find out if the hospital has surgeons with dedicated training for gastrointestinal cancers? Does the hospital have Tumor Board reviews – how often are they conducted and will your case be discussed there if you wish?
   2. Work with a major cancer hospital, even if it is far: Most experts in high-volume centers are willing to work with your local doctors. Usually, part of the treatment (for example, surgery) can be executed in the major center and the post-surgery treatment is executed locally.
   3. Research hospital’s Gastrointestinal Cancer volumes: How many cases of gastrointestinal cancer are treated in the hospital every year? High volume centers with multiple specialists available for gastrointestinal cancers may have better expertise and specialized medical infrastructure required.
   4. Consider Clinical Trials Availability: Ask whether the doctor or hospital has access to clinical trials and if you are eligible for any. Clinical trials are research studies that test new ways to treat cancer that you can be involved with. By being involved, you can help improve treatments and outcomes for future patients.
   5. Insurance Acceptance: Check if the hospital accepts your insurance. Check if the hospital has a desk that can assist you with claims.

Sources: Rogel Cancer Center; Cancer.Net