Introduction

Oesophageal cancer is a type of cancer that affects the oesophagus, which is the muscular tube that connects the throat to the stomach. It is the eighth most common cancer worldwide, with over 600,000 new cases diagnosed each year. In England, it is the 14th most common cancer, accounting for around 2% of all cancer cases.

Epidemiology

According to the latest statistics from Cancer Research UK, there were approximately 9,400 new cases of oesophageal cancer in England in 2018. Oesophageal cancer is more common in men than in women, and the incidence increases with age. The average age of diagnosis is around 72 years old. The incidence of oesophageal cancer in England has been increasing over the past few decades, particularly in the adenocarcinoma subtype, which is associated with obesity and gastroesophageal reflux disease (GERD) and usually occurs in the lower third of the oesophagus. The age-standardized incidence rate for esophageal cancer in England was 14.4 per 100,000 people in 2018.

Risk Factors

There are several known risk factors for esophageal cancer, including:

1. Tobacco and alcohol use: Smoking and heavy alcohol consumption are major risk factors for oesophageal cancer, especially squamous cell carcinoma. The risk increases with the amount and duration of tobacco and alcohol use.
2. Gastroesophageal reflux disease (GERD): Chronic acid reflux can cause inflammation and damage to the lining of the oesophagus, which can increase the risk of developing oesophageal cancer, especially adenocarcinoma.
3. Obesity: Being overweight or obese is a risk factor for oesophageal adenocarcinoma, possibly due to increased pressure on the stomach and lower oesophageal sphincter, which can cause reflux.
4. Poor diet: A diet low in fruits and vegetables and high in processed foods and red meat has been linked to an increased risk of oesophageal cancer.
5. Age and gender: Oesophageal cancer is more common in older adults and men.
6. Barrett’s oesophagus: This is a condition in which the cells lining the oesophagus change, increasing the risk of developing oesophageal cancer, especially adenocarcinoma.
7. Other medical conditions: Other medical conditions that can increase the risk of oesophageal cancer include achalasia (a disorder of the oesophagus), tylosis (a rare genetic condition that causes thickened skin), and Plummer-Vinson syndrome (a rare condition that causes difficulty swallowing and anemia).
8. Environmental factors: Exposure to certain environmental factors, such as radiation and certain chemicals, may increase the risk of developing oesophageal cancer.

It’s important to note that having one or more of these risk factors does not necessarily mean that a person will develop oesophageal cancer, and many people who develop the disease have no known risk factors. However, knowing about these risk factors can help individuals take steps to reduce their risk of developing oesophageal cancer.

Barrett’s oesophagus

Barrett’s esophagus is a condition in which the cells lining the lower part of the oesophagus change and become more like the cells lining the small intestine. This change usually occurs as a result of chronic acid reflux, which can damage the normal lining of the oesophagus over time. Barrett’s oesophagus is a risk factor for the development of oesophageal adenocarcinoma.

The link between Barrett’s esophagus and esophageal adenocarcinoma is due to the fact that the abnormal cells in Barrett’s esophagus can continue to change and become cancerous over time. It’s estimated that people with Barrett’s oesophagus are 30 to 125 times more likely to develop oesophageal adenocarcinoma than people without the condition. However, it’s important to note that not everyone with Barrett’s oesophagus will develop oesophageal adenocarcinoma, and not all cases of oesophageal adenocarcinoma are associated with Barrett’s oesophagus. The risk of Barrett’s oesophagus progressing to cancer is thought to be approximately 1 in 300 per year.

Those with further cell changes towards cancer (dysplasia) and those with longer segments of Barrett’s are at greatest risk of progressing to oesophageal cancer. Regular monitoring of Barrett’s oesophagus with endoscopy and biopsy can help detect any abnormal changes early and improve outcomes.

Signs and Symptoms

The signs and symptoms of oesophageal cancer can vary depending on the stage of the disease. In the early stages, there may be no symptoms at all. As the cancer progresses, the following symptoms may occur:

1. Difficulty swallowing (dysphagia)
2. Painful swallowing (odynophagia)
3. Regurgitation of food or liquids
4. Chest pain or discomfort
5. Unintentional weight loss
6. Chronic cough
7. Hoarseness or changes in voice
8. Fatigue or weakness

Diagnosis

If a person has symptoms that suggest oesophageal cancer, their doctor may order one or more tests to diagnose the disease. These may include:

1. Upper gastro-intestinal endoscopy (Gastroscopy): This procedure involves inserting a thin, flexible tube with a camera on the end (an endoscope) into the mouth and down the throat to examine the oesophagus, stomach and upper part of the small intestine.
2. Biopsy: During an endoscopy, the doctor may take a small sample of tissue (a biopsy) from the oesophagus to be examined under a microscope for signs of cancer.
3. Imaging tests: Tests such as CT scans, MRIs, and PET scans may be used to look for signs of cancer in the oesophagus and other parts of the body.

Treatment

The treatment of oesophageal cancer depends on the stage of the cancer and the overall health of the patient. The main treatments for oesophageal cancer include surgery, chemotherapy, and radiotherapy.

1. Surgery: Surgery is the main treatment for early-stage gastric cancer and involves the removal of the tumor and surrounding lymph nodes. There are two main types of surgery for gastric cancer: endoscopic resection (for early-stage tumors) and oesophagectomy (for larger tumors).
2. Chemotherapy: Chemotherapy is often used in combination with surgery to shrink the tumor before surgery (neoadjuvant chemotherapy) or after surgery to kill any remaining cancer cells (adjuvant chemotherapy).
3. Radiotherapy: Radiotherapy involves the use of high-energy radiation to kill cancer cells. It is often used in combination with chemotherapy before.
4. Targeted therapy: Targeted therapy involves using drugs that specifically target cancer cells. These therapies work by targeting specific molecules that are present on cancer cells or that support their growth and spread.
5. Immunotherapy: Immunotherapy for cancer is a type of treatment that harnesses the body’s immune system to fight cancer. It works by using drugs or other substances to stimulate the immune system to recognise and attack cancer cells.