Cancer of the Oesophagus
The oesophagus is a hollow muscular tube that connects the mouth to the stomach. It is around 25 cm long in adults. The inside of the oesophagus is normally lined by flat “paving slab” like cells called a stratified squamous epithelium. These sit upon a membrane that separates the lining from the muscle layers of the oesophagus.
Cancer can occur at any point along its length and the structure of the oesophagus can contribute to cancer progression. For example, unlike the rest of the digestive tract the oesophagus does not have an outer covering layer, which means that cancer cells can spread more easily and quickly to neighbouring organs.
There are two predominant types of oesophageal cancer: squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma (SCC) arises from the normal stratified squamous lining cells. Adenocarcinoma arises in fields of lining cells that have changed shape and size due to long-term exposure to stomach and bile acids. These cells change from looking like “paving slabs” under the microscope, to looking more like piled up columns, a condition known as Barrett’s oesophagus.
Worldwide the most common form of oesophageal cancer is squamous cell carcinoma. In many developed countries, however, the incidence of adenocarcinoma exceeds that of SCC. This is especially true of the UK and The Netherlands but is also true in North America, Australasia and Scandinavia.
Early signs of Oesophageal Cancer
These can include:
• Difficulty swallowing
• Weight loss without trying
• Chest pain, pressure or burning
• Worsening indigestion or heartburn
• Coughing or hoarseness
Don't ignore long term persistent heartburn - SEE YOUR DOCTOR
How common is Oesophageal Cancer
Cancer of the oesophagus is the 14th most common cancer in the UK but the 7th most common cause of cancer death. In England 40% of all sufferers will survive for one year, but by 5 years only 14% will still be alive. This is because the majority of patients present with incurable disease. It has either spread too far from the oesophagus into local organs or secondary tumours (metastasis) have developed at other sites in the body (typically lymph glands, liver and lungs).
The prognosis is dependent on the stage of the cancer and whether or not it can be cured with the best current treatments.
Less than 40% of patients can be offered curative treatment. These patients have a 74% chance of surviving for one year after diagnosis compared to 30% if the cancer is too advanced for curative therapy.
UK Mortality Rates from Oesophageal Cancer
• There were around 7,800 oesophageal cancer deaths in the UK in 2014, that’s 21 deaths every day
• Oesophageal cancer is the sixth most common cause of cancer death in the UK (2014)
• Oesophageal cancer accounts for 5% of all cancer deaths in the UK (2014)
• In males in the UK, oesophageal cancer is the fourth most common cause of cancer death, with around 5,200 deaths in 2014
• In females in the UK, oesophageal cancer is the sixth most common cause of cancer death, with around 2,600 deaths in 2014
UK Incidence of Oesophageal Cancer
• The United Kingdom has the highest incidence of oesophageal adenocarcinoma in the world: 7.2 per 100,000 in men and 2.5 per 100,000 in women
• There were around 8,900 new cases of oesophageal cancer in the UK in 2014, that’s 24 cases diagnosed every day
• Oesophageal cancer is the 14th most common cancer in the UK (2014)
• Oesophageal cancer accounts for 2% of all new cases in the UK (2014)
• In males in the UK, oesophageal cancer is the ninth most common cancer, with around 6,000 cases diagnosed in 2014
• In females in the UK, oesophageal cancer is the 14th most common cancer, with around 2,900 cases diagnosed in 2014
Global Incidence of Oesophageal Cancer
• There were 456,000 new cases of oesophageal cancer worldwide in 2012
• The majority, 398,000, were squamous cell carcinomas (SCC)
• 315000 of those cases were in Central and South-East Asia (210,000 in China alone)
• 52,000 were adenocarcinomas
• The worldwide incidence of oesophageal SCC is 5.2 per 100,000 but is substantially higher in males (7.7 per 100,000) than in females (2.8 per 100,000)
• Oesophageal adenocarcinoma has a global incidence of 0.7 per 100,000
Figure 1: Age standardised incidence of oesophageal cancer. (Adapted from Arnold M et al. 2015)
What causes Oesophageal Cancer?
Squamous Cell Carcinoma
Oesophageal squamous cell carcinoma arises through chronic irritation and inflammation of the oesophageal lining. Risk factors vary between countries and cultures but in general it is a disease of poor nutrition, poor–oral hygiene and poverty. The strongest associations are smoking and alcohol but consumption of hot beverages, high intake of barbecued meat and human papilloma virus infection have all been implicated.
Adenocarcinoma is rare globally but more common in wealthy, industrialised western nations. It is most common in middle-aged, caucasian, obese males with a history of excess alcohol consumption and smoking. Male-pattern obesity (fat carried around the waist and inside the abdomen) may be responsible for increased abdominal pressure and therefore acid reflux (often causing heartburn), going some way to explain why adenocarcinoma is seen far more commonly in men than women.
Adenocarcinoma of the oesophagus is strongly associated with gastro-oesophageal reflux disease (GORD) often described as Heartburn. GORD is a common disease whereas adenocarcinoma of the oesophagus is not.
GORD affects 1 in 10 adults on a daily basis and up to 2 in 10 weekly. Of these a further 1 in 10 will have Barrett’s oesophagus, the only known precursor for adenocarcinoma, the risk of progression to cancer in this population is around 1 in every 1000 patients per year.
Norman Barrett first described Barrett’s oesophagus in 1950. It is caused by long-term exposure to stomach acid, bile acids and pancreatic enzymes. Over time Barretts cells can sometimes change in structure becoming more disordered, a finding called dysplasia. Doctors classify dysplasia as low grade or high grade depending on how disorganised the cells appear under a microscope. If a patient has an upper GI endoscopy (a camera test to view the inside of the oesophagus and stomach) and high-grade dysplasia is found or low-grade dysplasia is present on two endoscopies 6 months apart doctors will consider using endoscopic therapies to remove all of the Barrett’s segment and prevent progression to cancer.
It is important to remember that the majority of patients with Barrett’s oesophagus will never develop oesophageal cancer.
Figure 2: An internal view of the oesophagus showing an adenocarcinoma (highlighted yellow) in a field of Barretts oesophagus (highlighted red).
How is Oesophageal Cancer diagnosed?
The typical symptoms of oesophageal cancer are of difficulty swallowing (food getting stuck), at first solids and then sometimes liquids. There may be weight loss and anaemia (a low red blood cell count). Whilst a number of other conditions can lead to difficulty swallowing, anyone who has this symptom should see their doctor.
The first test performed is usually an endoscopy (a camera test to view the inside of the oesophagus and stomach) with biopsies (small samples of the lining are painlessly removed and examined under a microscope).
The majority of patients are diagnosed with oesophageal cancer following a referral from their general practitioner (GP) or another hospital doctor (85%). A very small number (less than 1%) are identified because they are known to have Barrett’s oesophagus and undergo regular surveillance endoscopy. The remaining 14% present as an emergency. .
How is Oesophageal Cancer treated?
How is oesophageal cancer treated? Once staging has been completed a management plan will be developed and tailored to individual patients. This will include the stage of disease and other medical conditions, taking into account the wishes of the patient and their family.
Treatment of curable cancer
If oesophageal cancer is diagnosed early it can be cured. For the earliest stage cancers the tumour can be removed endoscopically (from the inside of the oesophagus in a similar way to the camera test used for diagnosis) without the need for major surgery or other treatments. If any Barrett’s oesophagus is present this will also be removed completely. More than one endoscopic treatment may be required.
Squamous cell cancer of the oesophagus often responds well to a combination of chemotherapy and radiotherapy.
Treatment of advanced and incurable cancer
In this setting treatment is aimed at improving the length and quality of life. Doctors may suggest a number of potential treatments or no treatment at all, depending on individual circumstances.
Surgery remains the mainstay of curative treatment for oesophageal cancer. The aim of surgery is to remove the tumour, the oesophagus, the lymph nodes (that may contain cancer cells) and the surrounding tissue and to restore continuity of the digestive tract. By far the most commonly performed operation is an Ivor-Lewis oesophagectomy that involves operating in the abdomen and the chest. In the UK 96% of operations are performed in this way.
Minimally Invasive and Robotic Oesophagectomy
The role of key hole (minimally invasive) and robotic surgery is expanding in oesophageal cancer. The perceived advantages are shorter recovery times, a reduction in complications and less post-operative pain. The UK’s ROMIO clinical trial (Randomised controlled trial of minimally invasive or open oesophagectomy) coupled with similar trials in France (MIRO) and Holland (TIME), is designed to compare the clinical and cost-effectiveness of minimally invasive and open surgical procedures in terms of recovery, health related quality of life, cost and survival. At present there is no convincing evidence that key hole surgery is better or worse than traditional open surgery and patients should be reassured that the type of operation that they receive will not determine their chances of survival or quality of life.
For more information please read our Booklet "Oesophageal Cancer - All you need to know"
Latest NICE guidelines for treatment of Cancer
Mimi McCord the founder of HCUK is as a patient representative on NICE – the National Institute for Health and Care Excellence and has been involved in the preparation of new guidelines covering the assessment and management of oesophago-gastric cancer in adults, including radical and palliative treatment and nutritional support.
These guidelines have just been published. https://www.nice.org.uk/guidance/ng83m.
Why Heartburn Cancer UK Exists
As a recognised and trusted authority in the field of Cancer of the Oesophagus, we know that with your help we can make significant inroads in the Prevention, Detection and Treatment of this disease by focussing on 5 key areas of action:
Education leads to a lasting change. We are working hard to influence public and social policy, to lobby politicians, to campaign for change, to promote greater collaboration amongst the medical profession, the public and the government. We are already in the process of developing a network of effective partnerships with businesses, the pharmaceutical industry, medical professionals and other like-minded groups. We intend to effect change and influence how this disease is perceived, detected, diagnosed and treated.
Our aim is to significantly reduce incurable oesophageal cancer in the UK.
Our renowned medical professionals, all experts in the field of oesophageal cancer, will continue to play a key role in research and trials designed to reduce the incidence of this appalling disease.
Early detection rates are vital to ensure a positive outcome. We are creating a communication network to facilitate greater awareness of the importance of diagnosing the disease early, identifying the symptoms associated with the disease and seeking medical help quickly. Oesophageal cancer affects everyone regardless of their race, gender or age.
We will ensure consistent support is available to everyone affected by Barrett’s Oesophagus, regardless of who they are and where they live. Information and advice is available to all those affected by the disease and to the people who support them, on our website or by telephone.
We need your help to bring this to the attention of your employees, friends & family or indeed anyone who might suffer from persistent heartburn!
You can make a difference. Perhaps you know someone who has suffered from persistent heartburn, Barrett’s Oesophagus or Oesophageal Cancer. Perhaps you run an organisation and would like to help. Why not make it your company’s corporate responsibility?
We are not content with standing still; we are determined to develop and grow a sustainable UK charity which continually re-invests to maximise the impact of its resources.
Working with UK businesses and voluntary organisations' our outward facing collaborative approach will ensure we are the first place to come to for reliable, up to date information about Heartburn, Barrett’s and Oesophageal Cancer.
HCUK - Information Centre
All you need to know about Heartburn, Barrett's Oesophagus, Oesopageal Cancer. If you need support we can offer advice. Please contact us on the "Ask our Doctor a Question" form, or you can join one of our Local Support Groups. You can also buy Heartburn Cancer UK Clothing and other HCUK Merchandise to help Raise Awarness and of course we would very much welcome a Donation to allow the charity to carry on offering free advise, Raising Awareness, Changing the Future and Saving Lives.