In Australia each year over 1000 people are diagnosed with oesophageal cancer (approximately 1in 256 people). Oesophageal cancer arises from the cells from the inner most lining of the oesophagus. There are two main types of oesophageal cancer, squamous cell carcinoma and adenocarcinoma. The squamous cell cancer derives from the cells that form the inner most lining of the oesophagus and world wide it came from the majority of cases although it is decreasing in incidences in Australia and accounts for less than half the cases. Adenocarcinoma develops in people where the lining of the inner most part of the oesophagus has changed in response to constant exposure to stomach acids. Our approach for patients diagnosed with oesophageal cancer involves treatment as part of a multidisciplinary management team that focuses on cancers of the oesophagus, stomach and pancreas. The team includes medical oncologists, gastroenterologists, radiation oncologists, pathologists and the operating surgeon.
The Princess Alexandra Hospital has taken a leading role in the management of oesophageal cancer in Australia and this expertise has extended to include the Greenslopes Private Hospital and Mater Private Hospital. Our patients are offered the latest treatment through clinical trials. Our major focus of interest in addition to trials has been research to improve outcomes following surgery as well as the identification of novel therapeutic targets aimed at improving cancer outcomes.
Through the clinic, patients are offered the latest in minimally invasive surgery as well as the latest developments in chemotherapy and radiation therapy for oesophageal cancer.
The oesophagus is a hollow muscular tube that carries food from the throat through the upper neck, chest and into the stomach where it is digested. Cancer of the oesophagus arises from the inner most lining. The most common form of cancer in Australia is adenocarcinoma and overall the disease effects approximately 1100 Australians per year. The incidence of adenocarcinoma is rising in Australia related to a combination of gastro-oesophageal reflux disease and obesity.
Squamous cell carcinoma of the oesophagus arises from the inner most layer and is very common in South East Asia. It is associated with alcohol ingestion and tobacco smoking. In Australia it is decreasing in incidence. Adenocarcinoma is now by far the most frequent form of the disease and is increasing in incidence. Adenocarcinoma is strongly related to gastro-oesophageal reflux disease and the development of Barrett’s oesophagus. Barrett’s oesophagus is a condition in which cells lining the lowest part of the oesophagus near the opening of the stomach change in response to abnormal exposure of gastric content particularly acid. The normal squamous lining of the oesophagus takes on a lining similar to the stomach and this is referred to as Barrett’s oesophagus. The presence of Barrett’s oesophagus increases when the risk of subsequent development of oesophageal cancer 100 fold. However the majority of patients with Barrett’s oesophagus do not develop oesophageal cancer and approximately half of the patient’s presenting with oesophageal adenocarcinoma have no antecedent history of Barrett’s oesophagus or reflux.
Tobacco use in any form increases the risk of oesophageal cancer. Long term heavy use of alcohol particularly in combination with smoking also increases the risk of oesophageal cancer. In addition to reflux in Barrett’s oesophagus, diet that is low in fruits, vegetables and certain vitamins and minerals increases the risk while conversely and the risk is reduced by consuming a diet high in fruits and vegetables. The accidental ingestion of alkali increases the risk as does end stage achalasia (a conditioning where there is no normal muscle activity in the oesophagus not to empty appropriately and dilate slowly over time). There is no sure means to prevent oesophageal cancer, however avoiding smoking and alcohol is the most effective way to reduce the risk. Effective treatment of heartburn is also important and this may be achieved through the use of medication or anti-reflux surgery.
The symptoms of oesophageal cancer can include difficulty swallowing which is the most common symptom and initially begins with solids and then includes liquids. Painful swallowing is also a symptom as is pressure being in the chest. Unexplained weight loss and hoarseness may also be related to oesophageal cancer.
If your Doctor suspects that you may have oesophageal cancer, such as difficulty swallowing, your Doctor may take a look inside the oesophagus using an endoscope (flexible fibre optic lighted instrument inserted into the mouth guided through the oesophagus into the stomach). This also allows your Doctor to take a sample of tissue which is important to make a diagnosis of cancer. You may also undergo a barium x-ray to show the lining of the oesophagus. Once your Doctor has diagnosed oesophageal cancer it is important to determine how to stage the disease. That is the determination of how far it is spread in the oesophagus and nearby organs or beyond. The most often used modality would include computed tomography (CT scanning), unfortunately this will show the disease has spread beyond the oesophagus in many patients. For those in whom it appears to be localised, patients will also undergo a Positron Emission Tomography (PET) as this will detect extra oesophageal disease in 10-15% of patients thought to have localised disease on CT scan.
Patients may also be offered another staging technique called endoscopic ultrasound which is similar to an endoscopy with an ultrasound probe on the end of the instrument. This provides a very close look at the layers of the oesophagus and can determine how far the tumour has spread through the oesophageal wall, whether it is attached to an adjacent organs and whether any lymph nodes are involved. This provides very accurate local staging and can help guide treatment with respect to the addition of chemotherapy and sometimes radiotherapy in addition to surgery. In addition to this it is very important to establish your past medical history and fitness to undergo maximum treatment.
The choice of treatment for oesophageal cancer depends on the stage of the disease. In the most advanced stages the investigations will have identified the secondary deposits of oesophageal cancer (metastasis) in organs such as the liver or lung and this is referred to as stage IV disease. Stages I-III relate to localised oesophageal cancer that may have spread into adjacent lymph glands but not more distant parts of the body. In combinations of surgery, chemotherapy and or radiation therapy are offered to patients depending on their stage.
With localised oesophageal cancer (that is not stage IV disease) surgery is the most common form of curative treatment when the patient is fit enough to withstand the surgery. Where the disease is localised to the oesophagus and thought to be early on staging studies, surgery alone can be curative. For more advanced localised oesophageal cancer the results with surgery alone are improved by the addition of chemotherapy or chemotherapy and radiation therapy combined.
If it is determined that surgery is appropriate with curative intent the procedure involves removing the majority of the oesophagus and the upper portion of the stomach. In addition, the adjacent lymphatic lymph glands are removed from the chest and the upper abdomen. The stomach is then converted into a tube and joined to the oesophagus either in the upper chest or in the neck. Our preferred approach is to use a minimally invasive technique which uses three or four small holes in the right side of the chest to remove the oesophagus, as well as 5-6 small holes in the abdomen to gain access to the stomach and a cut in the neck to join the stomach to the oesophagus in the neck.
We are now performing minimally invasive, robot-assisted oesophagectomy in selected cases. The surgical options will be discussed with your Doctor and personalized for each case.
Oesophagectomy is one of the most major operations that one can undergo. The mortality rate (risk of death after surgery) is less than 2% (that is 1 death per 50 operations). While the death rate is low, complications remain a problem and approximately 40% of patients will have some complications related to the surgery in the short term. Quality of life studies would suggest that it takes six to nine months to recover fully from the surgery. However most patients spend 8 – 12 days in hospital and are able to look after themselves without great difficulty after they have been discharged. The principal problem many patients face is fatigue. Because the stomach has been removed most patients have to eat small and more frequent meals. They will typically lose 10 – 15% of their body weight after this surgery but this should plateau and it does not typically go up or down a great deal once a set point has been reached. In addition because the join between the oesophagus and the stomach has been drastically altered many patients have problems with regurgitation and it is important not to eat meals within 1.5 hours of lying flat.
Complications that occur related to the surgery are most commonly related to the chest and pneumonia is the most common complication that is seen. Some element of collapse of the lung is sometimes seen and this is usually reversed with physiotherapy. Problems with the anastomosis (called an anastomotic leak) occur in approximately 1 in 10 patients but these typically resolve without any intervention where the join has been made in the neck. A need for intervention depends on the clinical situation at the time. Further problems in the neck can involve hoarseness which is seen in less than 5% of patients and usually resolves with time. Bleeding can occur requiring re-operation but this occurs in less than 1% of surgeries. A chyle leak can also occur in the chest (this is caused by leakage of tissue fluid from the thoracic duct) and this requires a second operation in a small minority of cases. In addition more general complications can occur such as bowel blockage, heart attack and deep vein thrombosis or even clots progressing to the lungs (pulmonary embolism).
Expert multi-disciplinary care is involved in all patients with oesophageal cancer and through this collaborative approach, better post operative outcomes have been achieved and world class results are available locally.
Chemotherapy is aimed at killing any cancer cells that may have spread from the oesophagus as commonly employed in oesophageal cancer. We prefer to give this treatment before surgery so the patients can recover from the surgery without intervention. Clinical trials have suggested a benefit to pre-operative chemotherapy as well as chemotherapy and radiation therapy. These will be discussed at the time of your consultation and the most appropriate treatment plan developed on a personalized basis. This is an ongoing area of research by our Group.
For the majority of patients with oesophageal cancer the disease would have spread beyond the oesophagus to more distant organs. This is referred to as stage IV disease and cannot be cured. However, treatment to relieve symptoms and potentially improve length of life are offered. For patients with very advanced disease or those who cannot tolerate chemotherapy and radiation therapy your Doctor may implant a stent which is a expanding metal tube that is placed into the oesophagus through the tumour and expands to keep the oesophagus open. This enhances swallowing and will allow patients to continue eating a diet to maintain their nutrition for as long as possible.
For patients who are able to tolerate more aggressive therapy, combinations of treatments involving chemotherapy and or radiation therapy are offered in the context of chemotherapy and radiation therapy. In addition the ability to participate in clinical trials for newer treatment regimens and agents are offered when available.
Survivorship and support
In addition to your Doctor and nurses other members of the multi-disciplinary team are available for you to discuss the many issues related to cancer. Your family are also a form of vital component of emotional and social support that all patients with cancer require. We would encourage you to seek their assistance wherever possible.
Once the treatment has been completed, you will continue to be seen through the clinic and the nurses are also available to discuss some of ongoing issues related to recovery from the surgery. Long term problems include dietary adjustments and eating habits. In addition patients can experience diarrhoea as a result of division of the vagus nerve that is required for the surgery. In addition some patients will experience cramping abdominal pain and diarrhoea (called dumping syndrome) that is the result of food entering the gastrointestinal tract too quickly after eating. Advice is available should you have any of these symptoms occur. We also actively encourage close contact with a dietician in the early phases of recovery from treatment.