Early detection of esophageal cancer for a better outcome

Esophageal cancer happens when normal cells in the esophagus change into abnormal cells and grow out of control. The esophagus is the tube that moves food from the mouth to the stomach

According to WHO 2018 statistics, esophageal cancer is the seventh most commonly occurring cancer in men and the 13th most commonly occurring cancer in women. There were over 500,000 new cases in 2018.

There are mainly 2 types of esophageal cancer (called squamous cell carcinoma and adenocarcinoma) and these have different characteristics, including the specific part of the esophagus affected, probable causative factors and their symptoms. 

Despite the specific type of esophageal cancer, esophageal cancer generally has poor outcome, hence, early detection is cornerstone of its management.

Generally, irrespective of the specific type, esophageal cancer has known risk factors such as cigarette smoking, high alcohol intake, known history of acid reflux disease, obesity, a high dietary fat intake, diet rich in nitrosamines (found mostly in cured meats, primarily cooked bacon, beer, some cheeses, nonfat dry milk, and sometimes fish) or diet deficient in vitamins A and C, and deficient in trace elements (diets with low fruit and vegetable content). Other risk factors include esophageal strictures, long standing history of taking very hot substances, corrosive substances.

Despite advances in the diagnosis and treatment of esophageal cancer, the overall outcome for esophageal cancer is very poor. Overall 5-year survival after diagnosis is only 8%.

The small number of patients who present early with stage 1 esophageal cancer have a very favourable outcome from surgery, with a 5-year survival exceeding 80% compared to patients who present with stage two and stage three disease who live for an average of two years, following surgery with the five-year survival rate being only 16 per cent and 13 per cent for stage two and three respectively, even with aggressive treatment in developed settings.

For the majority of patients for whom only palliative treatment is the option due to the advanced state of the cancer or the patient very weak for aggressive surgery and treatment at presentation, the median survival is generally less than 8 months. 

More than 60 to 70 per cent of all patients who present to hospital with esophageal cancer aren’t suitable for surgery due to advanced state of the disease.

 Cancer of the esophagus doesn’t usually present with serious symptoms until late stage disease, hence, it is important that everyone knows the symptoms and features that might raise any suspicion of early esophageal cancer so that early medical checkup is done to rule out late presentation of the disease.

Early signs might be of acid reflux disease such as longstanding heart burn, stomach pain (pain in the upper abdomen), non-burning chest pain, difficulty or pain on swallowing, or food getting stuck, persistent voice hoarseness, persistent sore throat, chronic cough, new onset asthma or asthma only at night, recurrent lung infections (called pneumonia), and waking up with a choking sensation. As the disease progresses, one develops difficulty swallowing, starting with solid foods and progressing to liquids, loss of weight, general body weakness, sometimes vomiting blood, or symptoms of advanced disease to other body parts such as liver, lungs and bones.

Upper gastrointestinal endoscopy is advised for all patients with longstanding heart burn and vague symptoms or alarm symptoms (including difficulty swallowing), and for all patients older than 55 years with persistent recent-onset of those symptoms to rule out esophageal cancer being the cause. Although the majority of patients referred under these guidelines will have other cause for their symptoms, this low threshold is essential if cancers are to be detected at an early, curable stage.

If at endoscopy the doctor identifies any abnormal growth or changes, a small piece is taken off during the procedure (called biopsy) and tested to rule out any cancer growth. The doctor then determines how closely the patient needs to be monitored and if there is any need of subsequent endoscopies and biopsies so that any cancer growth is detected early and early management offered.

Once the patient is found to already have esophageal cancer, further work up is done to rule out any involvement of other structures by the cancer, and treatment will depend on the specific type of cancer and its stage, among which any or a combination of surgery, chemotherapy, radiotherapy, or palliative care (end of life care) management can be offered.

Dr. Ian Shyaka ,

Resident in Surgery, Rwanda Military Hospital,