By Mr RC Stuart, MD, FRCS, Consultant Surgeon, Beacon Hospital
 Oesophageal cancer is one of the few cancers with a rapidly rising incidence. This is mainly due to a rise in the prevalence of Barrett’s oesophagus, a pre-malignant condition strongly linked to oesophageal adenocarcinoma, caused by gastro-oesophageal reflux disease (GORD). The incidence of squamous cancer of the oesophagus has remained relatively steady though a slight fall has been evident for the last decade as people stop smoking and have better nutrition. At the same time as the incidence of adenocarcinoma of the oesophagus has been rising there have been dramatic changes in the incidence and site of gastric cancer. Overall gastric cancer incidence has reduced by half, due mainly to a decrease in the incidence of distal gastric cancer, possibly due to a lower prevalence of Helicobacter pylori infection. At the same time there has been a migration of the remiasing gastric cancers towards the proximal end of the stomach. The consequence of both these oesophageal and gastric cancer trends is that the majority of these cancers now occur in the lower oesophagus, oesophago-gastric junction, and the proximal stomach. The association of these cancers with gastro-oesophageal reflux disease and poor diet, as reflected by obesity, is stronger than ever. As a result, the predictions are for these cancers to continue to increase in incidence for the next 20 years.
The recognition of the GORD – inflammation – Barrett’s metaplasia – dysplasia – cancer sequence has led to the introduction of endoscopic surveillance programmes for patients with Barrett’s oesophagus. The aim is to detect and treat dysplasia before an invasive cancer develops. A surveillance programme that detects an incident invasive cancer has failed to do its job. It is therefore imperative that if a patient is entered into surveillance that the programme is of a high quality. This is dependent on the protocol for taking and analysing the endoscopic biopsies. Paradoxically, a high quality surveillance programme can actually reduce the frequency of endoscopy procedures required to maintain a cancer free oesophagus. Current oesophageal research is looking for ways to perform an in-vivo analysis of the mucosa during the endoscopy, with the aim of reducing the need for biopsy and histopathology.
The rationale for surveillance endoscopy is that when dysplasia is detected it can be treated in order to prevent a cancer. The last 10 years has seen the introduction of endoscopic mucosal resection (EMR) as well as a number of mucosal ablation techniques. Even cancers with early submucosal invasion can be excised endoscopically with the aim of cure in the context of organ preservation. Larger area of dysplastic mucosa can be ablated by a variety of techniques including photodynamic therapy, laser and thermal ablation, argon plasma coagulation and more recently by the introduction of microwave therapy.
For the less fortunate patient who develops a more invasive oesophageal cancer clinical management has improved significantly over the past decade. This has resulted in a doubling of expected survival rates. However, the prognosis still remains poor and a key to management is the correct selection of patients for the various treatments on offer. Pre-treatment staging of the disease is critical in order to select patients for surgery as in the past many patients underwent oesophagectomy without any real chance of cure. CT scanning remains the cornerstone of this process but the introduction of Endoscopic Ultrasound (EUS) has made a particular contribution to oesophageal cancer staging. When EUS is combined with fine needle aspiration cytology (FNAC) of lymph nodes, distant from the primary cancer, patients with essentially metastatic disease avoid unnecessary surgery and receive alternative palliative treatments. In selected cases, other staging techniques such as laparoscopy, MRI and PET scans, may be required. In addition to determining suitability for surgery this staging process also helps select the appropriate patients for pre-operative neoadjuvant chemotherapy or chemoradiotherapy. Resection rates for oesophageal cancer have fallen from as high as 80% to as low as 25% in the past 2 decades.
The surgery of oesophagectomy used to be associated with a mortality of over 20% and only a minority survived beyond a year after surgery. Recent UK based audits of practice record a post-operative mortality of over 10% and a 1 year survival of just over 50%. Today, a patient can reasonably expect a post-operative mortality of less than 5% and a 1-year survival of over 80% after oesophagectomy. 5 –year post-operative survival of over 35% is now commonly reported in the literature. The reasons behind such improvements are multifactorial. The surgical technique has changed towards the philosophy of resecting the cancer itself and not just the organ of the oesophagus. En-bloc resection with formal lymphadenectomy is being used more widely as the surgery of choice. Neoadjuvant chemotherapy or chemoradiotherapy is being used more oftern. Oesophagectomy is one of the few cancer operations (along with total gastrectomy, pancreatectomy, and low anterior resection) for which there is overwhelming evidence that specialisation and centralisation of services improves short and long term outcomes. Both individual surgeon, as well as institution volumes, are important in improving outcomes after oesophagectomy. Centralisation of surgical services for oesophageal cancer is to be welcomed. There is certainly much more evidence for centralising oesophageal surgery than exists for many of the other cancers about which there is much more public debate.
Centralisation of surgical services does not however necessarily bring benefit to the oesophageal cancer patient who has a more advanced cancer requiring a palliative approach. The availability of local access to services will remain important and these patients are often overlooked when it comes to planning services. A patient with dysphagia and malnutrition from an advanced oesophageal cancer does not need to have to travel long distances to have an endoscopic dilatation, laser treatment or insertion of a stent for example. A devolved approach to other palliative services is needed and even delivery of chemotherapy or radiotherapy does not need the same level of centralisation that is required for surgical services. The importance of palliative chemotherapy and chemoradiotherapy in oesophageal cancer cannot be underestimated and huge improvements in drug selection, delivery and tolerance have been seen in the last decade. It is common to survive to between 12 and 24 months and in selected cases long-term survival can be achieved leading some to consider chemoradiotherapy as an alternative to surgical resection.
When a patient has an advanced cancer and is either unfit for chemoradiotherapy or has relapsed after treatment their prognosis is particularly poor. Despite this there is still an important need for an active approach to palliation and terminal care. Gone should be the days when someone dies purely from malnutrition due to obstructive dysphagia. Patients and their carers need to be educated to understand that prompt attention to inability to swallow greatly improves quality of life and will prolong survival. At the end of the day, despite all the efforts outlined above, nearly 90% of patients with oesophageal cancer will die from their disease and there is a real need to improve local palliation and terminal care access and services.
Oesophageal cancer is quite different from many less aggressive cancers, such as breast and colorectal cancer, in one very important respect. There are very few advocates for oesophageal cancer patients. Patients don’t survive long-term to recover fully and then take up the cause on behalf of other patients. Most families of patients are too distressed and traumatised by witnessing the rapid and unpleasant death of their loved ones. It is natural that they would prefer to forget rather than carry on a campaign that requires them to revisit unpleasant memories. In this respect a most welcome development has occurred with the establishment of the Oesophageal Cancer Fund (OCF). The OCF is a charity that was originally set up by friends of a very brave young woman, Lucinda Hyland, who died from oesophageal cancer in 2001, in conjunction with Professor Tom Walsh, oesophageal cancer surgeon and international expert at Blanchardstown Hospital in Dublin. More recently the OCF charity has responded to the wider community of oesophageal cancer patients in Ireland by becoming the national voice for oesophageal cancer. The OCF now runs a very successful national campaign of fundraising on their annual LOLLIPOP DAY which takes place this year on Friday February 27th and Saturday February 28th. In addition to fundraising for research into oesophageal cancer the OCF has core aims of improving public awareness about oesophageal cancer and helping to facilitate improvements in the patient journey through their experience with oesophageal cancer.
There are about 400 new cases of oesophageal cancer in Ireland each year.
Approximately the same number of people die from oesophageal cancer as there are road traffic deaths in Ireland each year. Early diagnosis allows more successful treatment.
The chief symptoms are:
- Recent onset of dysphagia
- Unexplained weight loss – which may precede dysphagia
Risk factors for developing oesophageal cancer include:
- Age: More likely as people get older; most sufferers are over 60
- Gender: More common in men, but incidence in women increasing
- Barrett’s: Long-term acid reflux increases the risk of adenocarcinoma.
- Heartburn: A long history of chronic heartburn.
- Obesity: There is increased incidence in obese patients.
- Tobacco Use: One of the major risk factors for squamous cancer.
- Alcohol Use: Heavy alcohol use is another major risk factor for squamous cancer.
About 70% of the people with oesophageal cancer have symptoms for more than three months before presentation.
Early diagnosis offers the best chance of cure.
- Dysphagia
- food sticking after swallowing
- any age
- Dyspepsia
- at any age with any of the following:
- dysphagia
- progressive unintentional weight loss
- persistant vomiting
- iron deficiency anaemia
- epigastric mass
- suspicious barium meal result
- any patient over 55 years of age with unexplained and persistent recent onset dyspepsia
- unexplained worsening dyspepsia and
- Barrett’s oesophagus
- Known dysplasia, atrophic gastritis, intestinal metaplasia
- Peptic ulcer surgery over 20 years ago
- Family history of upper GI cancer in 2 or more first degree relatives
- Symptoms without either dysphagia or dyspepsia:
- Persistent vomiting and weight loss
- Unexplained weight loss
- Unexplained Iron deficiency anaemia
Rapid access gastroscopy with biopsy is the investigation of choice.
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