Cancer Of The Esophagus Is Increasing, But Early Detection Is Available
When we think about the cancers which we fear the most
, what comes to mind? In my field of gastroenterology, which is the medicine of the digestive tract, most people would probably answer "colon cancer," which is why over half of the eligible population of the U.S. subject themselves to the colonoscopies we perform for them to help find and prevent colon cancer (still far less than the number of people who should have colonoscopies, by the way). Some people would answer "pancreatic cancer," which is certainly a rapid and deadly cancer that is often found too late for effective therapy. Others would answer "liver" or "stomach" cancers, both of which certainly should generate concern. Far fewer would answer "esophageal cancer," but more people should, as this too is an absolutely devastating and deadly disease that, like pancreatic cancer, is often found too late.Before we review the cancer, however, we should review the role of the esophagus in the digestive tract. The esophagus is a long and very muscular tube that conducts the food we eat from the back of our throats, down our necks, through our chests, and then finally to our stomachs. One misconception is that this food passageway and our breathing system share the same tubes (they don't, which is why we choke if food "goes down the wrong pipe"). Another is that food merely falls down the esophagus by gravity down into the stomach. In fact, it pushes it down with strong contractions so, if you wanted, you could stand on your head and drink water and it will still reach your stomach. The esophagus gets little thanks from the stomach for all of its efforts, as it is often the recipient of acid, bile, and other contents of the stomach that "reflux" up through a weakened valve (called a "sphincter") at the base of the esophagus back up into its interior. The irritation from these stomach contents into the esophagus is what causes our sensation of heartburn or reflux; is what causes esophageal irritation and ulcers; and is what can eventually lead to one type of esophageal cancer.
Sadly, esophageal cancer is increasing. Almost 17,000 Americans (equal to almost double the entire population or Norwell) are diagnosed with the disease every year, and nearly as many die, making for a distressingly high diagnosis to death ratio. The number of people with esophageal cancer has gone up 6-fold since 1975, and the number dying from it has gone up 7-fold. There are two types of esophageal cancer: squamous cell carcinoma (or SCC) and adenocarcinoma (or AC). SCC generally involves the upper and mid esophagus and is the most common type around the world, while AC and is often caused by acid reflux, itself often increased by obesity. AC involves the lower esophagus and is the more common type in the US. Smoking and alcohol are the two other major risk factors for esophageal cancer, especially SCC. Individuals who have had radiation therapy to the chest, head, or neck for other cancers (for example, breast cancer) also are at risk. Patients who have areas of their esophagus that have been found under the microscope to be progressing to cancer but are not yet cancerous (called Barrett's Esophagus) also have higher risk. Esophageal cancer, like other types of cancers, has the additional ability to metastasize, or spread around the body to distant sites as it grows.
The most common symptoms that cancer in the esophagus will cause is difficulty in swallowing food, especially bulky solids such as meats or breads, which will often feel like they stick or slow while going down. This tends to be progressive, with problems slowly worsening over time, often to the point where someone can only swallow soft foods or liquids. Pain with swallowing can also occur, as can pain in the chest or upper back. Weight loss, especially given the swallowing issues, often takes place as well. These symptoms are particularly worrisome because by the time they are noticed, the cancer is often very advanced. By some estimates, the cancer needs to block the vast majority, or about 75%-80%, of the open space in a given area of the esophagus before it even begins to cause symptoms felt by the patient.
Thankfully, we gastroenterologists are able to perform a test called an esophagogastroduodenoscopy (EGD) to find and diagnose esophageal cancer. This EGD is a test where we give patients medication to help them sleep (like during a colonoscopy) and then pass a long, thin narrow video scope down the mouth, through the esophagus, into the stomach, and finally into the beginning of the small bowel. We are able to completely see the entire esophagus and take small tissue samples (biopsies) if needed. The test takes 5 to 10 minutes and, as with a colonoscopy, most patients remember little to nothing of the procedure. Another similarity to colonoscopy is that people need to take the day off from work and be driven to the test and home, but unlike colonoscopy, there is no bowel cleansing preparation required beforehand.
Also unlike colonoscopy, where every average American aged 50 and older is recommended to have that screening procedure performed whether they have symptoms or not, there are currently no recommendations for the average American without symptoms to have a screening EGD to look for early esophageal cancer, although this may change in the future. Despite this lack of population-wide recommendations, there are researchers who suggest that some Americans without symptoms may wish to have an EGD to check for early disease. Individuals with histories of poorly controlled heartburn or reflux over a 3 to 5 year period or any history of treated symptoms of longer duration should consider having an EGD. Caucasians, especially men, seem to be of higher risk and those with smoking or regular alcohol histories even more so. Patients who are actually having suggestive symptoms such as swallowing difficulties, pain with swallowing, or weight loss of any kind should absolutely see one of us locally at Harbor Gastroenterology (or any other gastroenterology practice) for an EGD and a full evaluation. A "barium swallow", "upper GI series" or any other type of x-ray or radiological study is not at all an adequate substitute for having the full EGD done by a gastroenterologist to rule out cancer.
Therapy for esophageal cancer often includes some combination of surgery, chemotherapy, and radiation treatment, depending upon the type, location, and extent of the cancer. Despite its historical deadliness, progress is increasingly being made at improving the quality of life and survival of patients with this serious and underestimated condition. The most important thing, though, is not to delay seeing a digestive specialist if you believe you are having symptoms or are at higher risk for this disease.
Bret Ancowitz, M.D. is a
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