Treatment of the Patient with Oesophageal Cancer

Cancer of the oesophagus can be a particularly distressing condition as it may severely affect the patient’s ability to swallow therefore impeding their eating and drinking. This is compounded by the fact that the survival rate for the past five years remains low at around 5% (unchanged for about 20 years). This type of cancer is most common in men in their 60s (perhaps due in part to lifestyle factors, including alcohol intake, tobacco use and occupational risks).

The oesophagus is about 10 inches long and joins the pharynx to the stomach and is situated behind the trachea. It consists of several layers; the outer layer is a membrane of connective tissue, inside this is the muscle layer which helps by peristaltic action to move contents down into the stomach. Within this there are layers of mucus which help to lubricate the food to ensure it moves smoothly.

Adenocarcinoma is the most common type of oesophageal cancer, it is connected to acid reflux and obesity and generally affects the lower 2/3 of the oesophagus. If acid reflux persists it can lead to squamous cells being replaced with glandular cells (a condition known as Barrett’s oesophagus) which is a risk factor for later developing oesophageal cancer.

Squamous cell carcinoma affects the top third of the oesophagus, and it is this type of cancer which is linked with tobacco use and excessive alcohol consumption.

Oesophageal cancer generally presents as intermittent dysphagia. The dysphagia will develop with time. Patients may regurgitate food from their oesophagus, this should not be confused with the vomit of stomach contents. Coughing up copious amounts of saliva is common in the mornings as it has had chance to build up overnight.

Patients may find they are losing weight and may need to adapt their diet to include softer, moister foods. In later stages liquids only may be tolerated.

Oesophageal cancer is generally diagnosed after an endoscopy where a biopsy is also taken of any lesions found. A CT scan of the chest and pelvis may then be taken. This is to check if there has been metastasis; key areas for this are lung, liver, stomach and abdominal cavity.

Treatment is planned around information gained from scans, history taking and biopsies to determine the size of the tumour, tumour type and metastasis.

There are several investigations that may be carried out:

  • Endoscopic ultrasound to assess how far the cancer has spread into the oesophageal wall
  • CT scan – this will show up metastasis and lymph node enlargements
  • Positron emission tomography scan wherein the patient is given an injection of a radioactive substance (fludeoxyglucose F18) that is absorbed by fast-dividing cancer cells
  • Cardiopulmonary exercise test – this is to assess a patient’s risk under general anaesthetic
  • Laparoscopy – requires a general anaesthetic, an interval inspection of the abdominal cavity

Unless there has been metastasis, surgery will be offered. If there has been metastatic spread the patient will be referred for palliative care. In this case no further tests are necessary.

The only cure of oesophageal cancer is through surgery. However, 70-80% of oesophageal cancers return after surgery. The other options, if either the patient is unsuitable for surgery or if the cancer has metastasised are chemotherapy, radiotherapy and palliative care.

Preoperative chemotherapy may be required if the tumour has progressed past two stages, this will be to shrink the tumour; chemotherapy may be scheduled for three three-week cycles before surgery. Chemotherapy is often continued after surgery as well to reduce the risk of metastasis.

The surgery itself is a major intervention and can take around eight hours. The affected part of the oesophagus is removed with up to half of the stomach. The part of the stomach that is removed is formed into a tube and used to replace the diseased part of the oesophagus.

Post-surgery the patient will be monitored for at least 24 hours in ITU with particular concern for respiratory insufficiency and also sepsis as a result of anastomatic leak. The patient will be NMB for about a week to allow healing. Fluids are administered through a central line, and nutrition through a jejunostomy tube (which stays in place for two weeks post surgery). A nasogastric tube will also be inserted to allow release of gas or fluid from the stomach. After about a week after surgery the patient may be encouraged to drink and begin eating a soft diet. The swallow may be strange at first but will improve and become normal in time.

It may take up to a year for a patient to recover after oesophageal surgery – acid reflux may be a problem as the cardiac valve is removed during surgery. Patients may find extra pillows at night may help, and not eating for an hour before bed. Diet will be modified as the stomach is smaller so the same volume of food may need to be distributed more evenly throughout the day. Patients might not get hunger sensations any more which can make the need to eat little and often more difficult.

Recurrence of the cancer is common. Most patients will experience this. Any dysphagia after surgery needs to be discussed. It might simply be over-granulation of the anastomosis which can constrict; if this is the case, a balloon dilation of the oesophagus may be necessary (sometimes more than once). It is important to remember that the survival rate for oesophageal cancer is low and that recurrence is common.

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