Oesophageal Cancer

Oesophageal cancer is a condition which has become commoner as the societal factors which cause gastro-oesophageal reflux have increased. It usually effects people over 45 years of age but can be seen in people younger than this in exceptional circumstances. Whilst it has a good prognosis if identified at an early stage, particularly in patients who are fit for more aggressive intervention it commonly presents in frailer patients, who have significant comorbidity and at a late stage of disease.

There are two common forms oesophageal adenocarcinoma which is thought to arise from glandular tissue within Barrett’s oesophagus in those who commonly have a history of reflux and squamous cell cancer which arises in the squamous mucosa which normally lines the oesophagus.

Adenocarcinomas are thought to occur in patients with pre-existing Barrett’s oesophagus. Those patients with the best prognosis tend to be those in whom the cancer is either discovered incidentally whilst they are undergoing upper gi endoscopy for other indications or those who are undergoing regular surveillance in whom the cancer is detected before symptoms (usually swallowing) arise. This is why in those patients who are known to have extensive Barrett’s oesophagus and consequently a higher risk of a pre-malignant change known as dysplasia (either low or high grade) surveillance currently in the form of repeated endoscopy is usually offered. In patients where the length of Barrett’s is limited, usually less than a few centimetres, the risk of repeated endoscopy is higher than the risk of cancer (less than 1 in 500) so current guidance is that these patients should not be offered  or repeated surveillance. This may of course change as surveillance methods evolve and develop. In those who present with symptoms of difficulty swallowing, solid food getting stuck, disease is often more advanced. This is why patients who experience the sensation of solid food sticking as they swallow should be considered for early referral and endoscopy. Whilst difficulty swallowing solids is the commonest presentation of oesophageal cancer, oesophageal cancer is just one of a long list of potential cause of this symptom. A negative endoscopy is a hugely re-assuring finding since this is the most sensitive test available for detecting such tumours and they are usually easily visible on careful inspection with an endoscope.

Squamous cell cancers are less common, tend to arise in the upper oesophagus and cause similar symptoms to those of adenocarcinoma.

A range of treatments are available to treat oesophageal cancer.

Treatment is only undertaken after careful assessment of the patient’s individual case, their fitness for intervention and appropriate staging of their disease. Staging is a process by which the spread of the disease, into surrounding tissues (local invasion) and to distant organs(distant or metastatic disease) has been properly assessed. This may involve scans such as CT or endoscopic ultrasound following the initial endoscopy.

Usually the best course for further treatment is decided by a multi-discipliinary team consisting of nurses, gastroenterologists, surgeons and cancer specialist (oncologists). These “multi-discplinary teams usually meet on a regular basis (weekly usually). Patients are then reviewed or contacted following an MDT discussion and further intervention arranged. Of course some clinicians will keep patients informed along this journey, which can sometimes take longer than we would like.