Oesophageal Cancer

There are about 400 new cases of Oesophageal Cancer in Hong Kong every year, males are more susceptible to this disease than females with about 300 cases.

The disease is more common in the elderly too. The incidence rate of Oesophageal Cancer in Asia is significantly higher than in western countries. It may be related to the dietary habits of Asians.

The cure rate of Oesophageal Cancer has increased along with the advancement of medicine. The cure rate of Oesophageal Cancer in stage I is as high as 80%. Early diagnosis can increase the chance of cure.

(Special thanks to Dr. K H AU, Associate Consultant, Clinical Oncology, Queen Elizabeth Hospital for reviewing the information of this page.)

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Oesophagus (gullet) is a tube like organ of 25cm to 30cm long, running from the throat to the stomach. Gullet does not have digestive function, it keeps wriggling for carrying food to the stomach for digestion. Malignant tumor in the gullet is called Oesophageal Cancer. Genetic mutation in the gullet tissue cells leads to malignant transformation of cells, which can happen in any part of the gullet, e.g. neck (upper part), chest (middle part) and the junction of gullet and stomach (lower part).  Depending on the type of cells, it is classified into squamous cell carcinoma (cancer in the outer layer of skin) and adenocarcinoma (cancer in the glandular tissue).

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There are no definite causes of Oesophageal Cancer so far, but it may be related to long-term smoking, excessive drinking of spirits, acid reflux and dietary habit, e.g. eating a lot of preserved and smoked food.

If you belong to the following categories, you should pay special attention:

  • Aged 60 or above, male
  • Heavy drinker
  • Smoker
  • Fond of preserved or smoked food
  • Like to drink very hot liquid or soups
  • Acid reflux
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The following ways can help prevent Oesophageal Cancer:

  • No smoking
  • Avoid drinking spirits
  • Less or avoid intake of pickled or smoked food, e.g. salty sauerkraut, preserved meat and betel nut, etc.
  • Avoid eating very hot food (hot soup)
  • Take care of acid reflux as soon as possible
  • Less intake of high-fat food, eat more fresh fruits and vegetables and high fiber foods
  • Maintain a healthy body weight
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相片    The first symptom experienced by most Oesophageal Cancer patients is progressive difficulty in swallowing, but patients may not be aware of it and change their eating habits unconsciously. Since the patient cannot eat properly, he/she will lose weight and malnutrition resulted. When you experience difficulty in swallowing, weight loss for unknown reason and heartburn, you should consult your doctor as soon as possible.

The early stage symptoms include:

  • Difficulty in swallowing dry solid food
  • Coughing
  • Discomfort and pain in the chest during eating
  • If tumor appears in the upper part of the gullet (near the throat), there will be a feeling of discomfort in the throat or something in the throat when swallowing
  • If tumor appears in the middle part of the gullet (near the chest), there will be pain behind the chest bones or back pain during eating
  • If tumor appears in the lower part of the gullet (where it connects with the stomach), there will be a bloated feeling in the abdomen

The symptoms of later stage Oesophageal Cancer include:

  • Difficult swallowing will intensify. Gradually, patient can only eat semi-liquid food. Finally, patient may not be able to swallow liquid or saliva
  • Tumor in the gullet disturbs normal digestion in the stomach. Patient may feel nausea or even vomit and have regurgitation (bringing food back up)
     
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If you have difficulty in swallowing, or feeling painful or burning in the gullet when eating, or feeling something near the throat and chest, you should see your family doctor even though these symptoms are not necessarily resulted from Oesophageal Cancer. Your family doctor will refer you to specialist for treatment if needed.相片

(1) Barium swallow and meal examination
Since the gullet is invisible under X-ray, patient has to drink a contrast containing barium before examination. If there is tumor, the gullet will be narrowed. Endoscopy and biopsy have to be performed to fully determine the existence of tumor.

It takes 15 minutes to drink the barium contrast. Patient would not feel unwell but the barium may cause constipation. Thus, patient needs to drink more water for a few days after the examination and may need to take some mild laxative (a type of medicine that can help empty the bowels).

(2) Oesophagogastroduodenoscopy (OGD)
Doctor can observe any lesions in the gullet directly by this test. Doctor uses a tube-shape endoscope, which looks like a thick cable, to pass through the patient’s gullet to check any change in tissues by naked eye, and remove specimen from suspicious area for pathological examination to confirm whether it is cancer or other diseases.

During the OGD, patient shall lie down and may need sedative injection to ease the discomfort caused by the test and the throat may need local anesthesia. Patient should not eat or drink 4 hours after test until the effect of anesthesia disappears. Some people may have sore throat afterward, which is normal and usually will recover in 2 days.

Generally, this test does not require staying overnight in the hospital. But patient may need local anesthesia and sedative injection, therefore, patient should better be escorted home by friends or family after the test.

Examination for Spread of Oesophageal Cancer
If patient is confirmed to have Oesophageal Cancer by tests, doctor may still need to perform further tests to ensure whether the cancer cells have spread and in which stage it is so as to determine the most appropriate treatment for patient. Tests include:

(1) Computerised Tomography (CT) Scan
CT scan is a high-precision X-ray test which can show the 3D image inside the body.  It takes about 15 minutes.

Patient should fast in the 4 hours before the scan. Doctor will inject a contrast into the patient before the scan to ensure a clear image to be shown. In a few minutes, you may feel hot all over the body. If patient is allergic to iodine, has asthma or other history of allergy, he/she may have very strong reaction to this contrast, and the doctor should be informed before test.

CT scan does not cause any pain. Most people can go home immediately after the scan.

(2) Endoscopic Ultrasonography
The examination of Endoscopic Ultrasonography is same as OGD. The main difference is this endoscope has a small ultrasound probe at the end, which can reach deep inside the gullet to detect the gullet intine and the area around. Doctor can have a better understanding of tumor and to determine if there is enlargement of the lymph glands nearby.

(3) Bronchoscopy
By passing a soft, thin endoscope through the mouth, throat, trachea and bronchi and their branches, doctor can observe the condition of tissues through the lens to know whether the tumor affects respiratory organs of trachea, bronchi, etc.

(4) Positive emission tomography scan (PET scan)
It is an advanced isotope imaging technology for detecting spread of cancer cells in other parts of the body.

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相片    If tumor is confined to an area or has not spread to the organs nearby, doctor will consider one of the following solutions to eradicate the tumor:

(1) Removal surgery - doctor shall decide whether to remove part or the entire gullet depending on the patient’s conditions and use the stomach or part of the gut to replace the removed gullet. The patient can still eat solid food. Surgical treatment is usually used for Oesophageal Cancer in the middle or lower part of the gullet. If Oesophageal Cancer is near to the throat, the throat together with the vocal cord may need to be removed in the surgery.

(2) Radiotherapy (use of high-powered radiation to destroy the growth and division of cancer cells) and synchronous chemotherapy (use of anti-cancer drugs to destroy the growth and division of cancer cells)

(3) Surgical removal after synchronous chemotherapy with radiotherapy

Generally, radiotherapy and chemotherapy are more suitable for tumor in the upper part of gullet while all 3 solutions can be considered for treatment of tumor in middle and lower part of the gullet.

If there is sign that the tumor has spread far away or intruded into the main artery, or the patient is very weak, doctor can only perform palliative care to relieve the swallowing problem and maintain his/her quality of life. Methods which can be applied include:

  • Tube feeding - place a plastic tube via the nose or abdomen wall into the stomach for feeding
  • Gullet expansion - use a stent to expand part of the gullet to help swallowing
  • By-pass surgery - connect a portion of colon or small intestine to the upper part of the gullet bypassing the obstructing tumor
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The gullet tumor itself will continue to grow, making swallowing more difficult and causing serious weight loss and malnutrition. Tumor will also spread to the lymph and organs nearby and even erode the gullet tissues as well as causing fistula (an abnormal connection or passageway between two organs or vessels) between gullet and trachea. If fistula is formed, the food and drinks the patient takes in may enter into lungs through the trachea and cause pneumonia.

Possible complications of surgical removal include the connected part between gullet and stomach does not heal well or has leakage, pain / infection in the wound and acid reflux.

Possible side effects of radiotherapy and chemotherapy include temporary difficulty in swallowing, nausea, vomiting, loss of appetite, inflammation of gullet, hair loss, etc.

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There are a lot of things to take care during the recovery process. Better understanding of the illness will help patients face the disease with a positive attitude.

Regular follow-up: after treatment, doctor will arrange regular follow-up for the patient. Patient should inform the doctor as soon as possible if he/she discovers any new symptom.

Diet

  • Some patients with severe malnutrition need nutrition supplement through gastric catheter or even intravenous infusion
  • Ask for good nutrition supplement advice from dietitian
  • Treatment may affect appetite. Patient should choose what he/she likes to eat and the dishes that can enhance appetite
  • Meal should be delicious and light for better digestion and absorption. Avoid too greasy food
  • Removal of stomach makes the patient feel full even he/she only eats a little. Patient should eat less and more frequently. Patient should not have ill-balanced diet or even overeating
  • Relaxing environment, pleasant mood and slow down while eating

Exercises: avoid over-exhaustion during recovery. However, patient should do appropriate exercises (e.g. walking, jogging, playing Tai Chi) to enhance physique and anti-cancer capability.

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