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Esophageal Cancer: Symptoms, Diagnosis, and Treatments

CDHF

Written by: CDHF

Updated: June 7th, 2023

This article is a Q&A article format from our CDHFTalks: Esophageal Cancer, with answers by Dr. Setareh Samimi, hemato-oncologist, Sacré-Coeur Hospital.

What are the types of esophageal cancer?  What is the cause?

Esophageal cancer is the eight most leading cancer worlwide, it’s prevalence varies depending on different parts of the world.

There are two main types of oesophagus cancer, one is called squamous cancer which is usually more in the upper and middle area of the oesophagus, so we call it cervical and middle oesophagus and the other one is called adeno carcinoma which is mainly in the distal or the inferior part of the oesophagus.

Like most cancer, these can also have tumor detach and spread to other organs which we call metastasis.

What are the causes of esophageal cancer?

There is no main cause that explains why this cancer happens, however there are multiple risk factors that are known and have been implicated. They could vary depending on geographical and on the sub-type of this cancer, however the main ones include:

What are the signs and symptoms of esophageal cancer?

Typically patients can have some discomfort or difficulties swallowing whether it’s the saliva, food starting from more solid and then liquid food. The discomfort can be felt more in the throat area or lower in the mediastinum, between the chest. This can be associated with pain. Pain can be on the same location or felt in the back, like a point in the back. People can feel that their voice changes (hoarseness), and sometimes coughing can be associated. Futher, spitting or throwing up blood can be seen. Sensation of reflux that gets worse and worse can be also a symptom. Loss of appetite, weight loss is something that is usually seen as well.

To review, signs and symptoms include:

  1. Discomfort/difficulties swallowing
  2. Chest Pain
  3. Change in voice: Hoarseness
  4. Cough
  5. Bloody spit/vomit
  6. Loss of appetite/Weight loss

How is the diagnosis of oesophagus cancer made?

An endoscopy which is called a gastroscopy or EGD is a camera that goes through the mouth to the oesophagus where the tumor will be seen and a biopsy will be taken. Another endoscopy used is called echoendoscopy EUS, which has an echography probe attached to the endoscopy which allows better imaging of the depth of the tumor in the oesophagus and also of the lymph node area around it, to do biopsies if needed, and also to have a better look at the liver and the peritoneum to see if there are already evidence of spread disease.

In radiology, a CT scan of the thorax, the chest, abdomen and pelvis is used to see the extend of the tumor, the lymph node area around it and if there’s a spread of the disease to the other organs, for example the lungs, distant lymph nodes, bones or liver.

The PET scan (Positron Emission Tomography) is another imaging that allows you to see if there’s distant metastasis that were not catched on the CT scan.

The blood tests can also be helpful in indicating some signs or show the comorbity of the patient that might dictate or guide treatment options.

To review, diagnosing esophageal cancer can be done through :

  1. Endoscopy
  2. Echo-Endoscopy (Ultrasound)
  3. CT Scan (Computed Tomography)
  4. PET Scan (Positron Emission Tomography)
  5. Blood tests

How do you Treat Esophageal Cancer?

Treatment will depend on the stage of the disease. If the disease is localized and there is hope for curative intend, most of the time surgery will be part of the treatment plan. Before the surgery there will most likely be treatment that is called new adjuvant, meaning that the treatment could be either with chemotherapy alone or with chemoradiation depending on the choice of the medical team who will look at the imaging and the other characterics of the tumor of the patient to make the best decision.

There is as well sometimes study protocols that could be indicated. Once the surgery is done depending on the protocol that was used, there could be more chemotherapy afterwards or sometimes immunotherapy depending on the results of the pathology specimen after the surgery. In some cases, the disease is not operable or the patient has comorbidities that don’t allow a surgical act, however the disease is still contained and sometimes we can still aim for a curative intend with chemoradiation that we call radical chemoradiation.

Lastly, for patients that have a more advanced disease or a disease with metastasis or a stage 4 disease, the intend is to try to control the cancer, prevent it from progressing, allowing for more time for the patients and also hoping to have better control of their symptoms to alleviate them from the symptoms thet might have. In those cases, most of the time, it will be a chemotherapy with added immunotherapy or other target therapy depending on the pathology and the molecular testing that will be done on the biopsies of the tumor.

And in some more advanced cases, we can also use radiation for palliative, either on the primary tumor or on metastasis that causes pain. Further, somestimes a stent can be used to open up the oesophagus to allow the patient to eat better.

To review, treating esophageal cancer can be done through :

  1. Surgery
  2. Chemotherapy
  3. Radiation therapy
  4. Chemoradiation (Combined chemotherapy and radiation)
  5. Immunotherapy (Boosts immune system to fight cancer)
  6. Targeted drug therapy

Post Treatment Management

For patients that have a curative intend after the treatment, there can also be psychological factors such as anxiety and the depression, and it’s very important to have those discussions with your nurse or your doctor to be referred to the right clinicians with the psychology help that is needed.

Patients can also have trouble with their nutrition afterwards, especially after some of the surgeries. Again, it needs to be addressed with your healthcare team, and make sure that a dietitian is part of the team to help in that context.  Sometimes it’s needed if there’s some narrowing or stenosis, sometimes we do go back and try to dilate if that is a complication following the treatment. With the chemotherapy, sometimes patients will describe some memory loss or trouble with concentration, this is usually a temporary side effect that with time will go away.

Finally, for the follow-up, it will depend on your team and on different guidelines, but mostly follow-up will be done for the years to come to make sure that you don’t have any symptoms that would trigger your doctor to want to investigate or do imaging and make sure the disease is not back.

Post treatment management to keep in mind includes:

  1. Psychological – Anxiety, Depression
  2. Diet and nutrition
  3. Stenosis (narrowing of the esophagus)
  4. Temporary memory loss/concentration

This is a very brief overview / summary of symptoms, diagnosis, and treatment options pertaining to esophageal cancer, meant to give you the opportunity to ask more precise questions to your doctor if needed.

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