What is cancer of the oesophagus?

Cancer of the oesophagus or gullet develops as a result of cell changes in the lining of the oesophagus.

There are two main types of cancer of the oesophagus: squamous carcinoma, which is more common at the upper end of the gullet, and adenocarcinoma, which is more common at the lower end, particularly around the junction between the gullet and the stomach.

There has been a recent increase in the proportion of tumours arising close to the junction of stomach and gullet, but the reasons for this are not yet known.

In a condition called Barrett's oesophagus the lining of the gullet changes to being more like the lining of the stomach. Patients with Barrett's oesophagus are at an increased risk of developing cancer of the oesophagus and may benefit from regular follow-up and supervision by a doctor.

What causes cancer of the oesophagus?

It is thought that smoking and alcohol, among other things, can contribute to cancer of the oesophagus. (There is some evidence that spirits are the most dangerous type of alcohol to drink in connection with this particular type opf cancer.) This could account for the marked regional variation within Europe. For example, cancer of the oesophagus is twice as common in eastern Scotland as it is in the south of England.

There is also a particularly high rate in Normandy in France which has been blamed on drinking Calvados, an apple brandy. It is also 10 times more common in southern China than it is in the UK. These differences are probably related to diet as people in southern China eat a lot of heavily smoked and salted fish.

In the UK, iron deficiency used to be a common cause of cancers in the upper gullet, particularly in women. But with better diet and better medical care during pregnancy, this problem has now been virtually eliminated.

The disease is three times more common in men than in women and is more common in people over the age of 60.

What are the symptoms of cancer of the oesophagus?

The first symptom of the disease is almost always difficulty in swallowing. There is the feeling that food is getting stuck, often behind the lower end of the breastbone. At first the problem is only with solid food but later even semi-solids and liquids can cause problems.

Pain felt between the shoulder blades can also be troublesome. This discomfort is sometimes triggered by eating.

Another characteristic symptom is regurgitating unaltered food a few minutes after having difficulty swallowing the food. The patient often tries to handle these problems by eating less and avoiding solid food. This causes weight loss and fatigue.

Later on, heartburn, vomiting, and vomiting of blood may become the dominant symptoms. The early symptoms are relatively minor and tend to creep up on patients. This means it is often several months before they consult their doctors.

How is cancer of the oesophagus diagnosed?

It can be diagnosed by using X-rays using special dye. Before the X-ray picture is taken, the patient will be asked to swallow a beaker of a whitish fluid called barium. X-ray pictures are taken as the barium travels down the gullet and into the stomach. The procedure is completely painless and provides valuable information about the size of any abnormality present.

It does not provide a firm diagnosis though any irregular narrowing of the gullet would strongly suggest that there may be a cancer present. The definitive diagnosis is made through direct vision using a camera attached to a flexible tube (an endoscope), which makes it possible to take a tissue sample (biopsy). The endoscopy (sometimes called a gastroscopy) is carried out while the patient is under sedation.

A long flexible tube, about the thickness of a fountain pen, is passed through the mouth, over the back of the tongue and down into the gullet and stomach. The tube is connected to a camera through which the doctor can inspect the lining of the gullet and assess whether or not it is normal. A sample (biopsy) will be taken from any abnormal or suspicious areas.

After processing, these samples will be examined by a pathologist who will decide whether or not there are any cancer cells present. It usually takes 7 to 10 days after the endoscopy before the pathologist's report is ready.

A CT scan is often performed to assess whether or not the disease has spread either locally or to the liver. This is a particularly important investigation if surgery is being considered.

How is cancer of the oesophagus treated?

Treatment may consist of surgery, radiotherapy, chemotherapy or a combination of these. The best chance of cure is with surgery. Patients who are in good general condition and who have small tumours, have more than a 25 per cent chance of cure with surgery