Esophageal cancer

Esophageal cancer is a malignant tumor disease of the esophageal mucosa. The medical term for esophageal cancer is esophageal carcinoma. Doctors divide esophageal cancer into two types that are to some extent also treated differently.

Squamous cell carcinoma of the esophagus

The tumor originates from the epithelial tissue of the mucosa. 

Adenocarcinoma of the esophagus

Glandular cells have degenerated. It occurs almost exclusively at the junction between the esophagus and stomach. 

In many of those affected by it, esophageal cancer only causes symptoms when the disease is advanced. At this time, the tumor is already bigger and causing noticeable problems. 

A typical warning signal is discomfort when swallowing. The tumor is already constricting the esophagus by then. Difficulty swallowing initially occurs during consumption of solid food. As the disease progresses further, the tumor can also impede swallowing of soft food and liquid. 

Symptoms that may indicate a tumor disease in the esophagus are: 

• persistent pain or discomfort when swallowing 
• frequent swallowing 
• loss of appetite and weight loss 
• vomiting for no reason, vomiting blood 
• blood in the stool (tarry stools) 

Anyone with symptoms persisting over an extended period of time should not hesitate to seek an appointment at a medical practice. General Practitioners can already narrow down what is causing the symptoms and, if necessary, initiate further diagnostic steps with specialists. Medical specialists responsible for the esophagus are called gastroenterologists.

Esophageal cancer can – like any other cancer – develop purely by chance. A cause for the changed behavior of cells cannot be proven with certainty in individual patients. Various factors are often working together when cancer develops.

However, scientists have determined factors that statistically increase the risk of esophageal cancer. Some concern lifestyle, others are caused by pre-existing conditions:

• smoking 
• high levels of alcohol consumption 
• chronic heartburn 
• being overweight 
• a malfunction of the sphincter muscle at the junction between the esophagus and stomach in which those affected have difficulty swallowing and food repeats on them 
• radiation therapy in the area of the chest or neck 
• a chemical burn of the esophagus with acid or caustic solutions 
• drinking very hot drinks (likely association) 

Further information about the risk factors for esophageal cancer can be found on the German Cancer Research Center’s Cancer Information Service website (in German).

To begin with, the tumor is restricted to the topmost layer of the mucosa. If the tumor grows further, it gets into deeper layers of the esophageal wall. Over time, the tumor disease can spread to neighboring tissue, into lymph nodes and other organs. 

Tumor cells in other organs (metastases)

With the bloodstream or lymph stream, cancer cells can get into other organs and form what are known as metastases. In the case of esophageal cancer, metastases most commonly occur in the lymph nodes, liver and lungs. But other organs can also be affected.

The current examination to clarify difficulty swallowing or pain in the area of the esophagus is an inspection of the esophagus. The medical term for the examination is esophagogastroduodenoscopy. Along with the esophagus, the doctor also examines the stomach and duodenum.

During the esophagoscopy, the doctor guides a tube as thick as a thumb (endoscope) into the esophagus through the patient’s mouth. A video camera is attached to the end of the tube. It sends the doctor an image of the esophageal mucosa.

If the doctor notices during the examination that the mucosa of the esophagus is changed, he will take tissue samples at the affected sites. He will then send these to a laboratory. There, specialists will check under a microscope whether there are cancer cells in the tissue samples.

Cancer diagnosis, what’s next?

If the suspected tumor has been confirmed, doctors will suggest further examinations. With these, they can ascertain how much the tumor has already spread and whether metastases have formed. Specialists use the term staging for these examinations.

Staging

Imaging techniques are used to determine how far esophageal cancer has spread. Additional examinations can be used as needed. The techniques used depend on the individual situation – not all patients need all examinations.

The following imaging examinations may be considered:

• Endoscopic ultrasound: endoscopic ultrasound has a similar procedure to the inspection of the esophagus. The difference: with endoscopic ultrasound, an ultrasound transducer is on the end of the endoscope.
• Ultrasound
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Other examinations: positron emission tomography (PET), x‑ray, inspection of the windpipe and bronchial tubes (bronchoscopy), inspection of the organs inside the abdomen (laparoscopy)

The attending physicians then create a treatment plan based on the staging results.

For information about individual examination methods, see the website of the Cancer Information Service of the German Cancer Research Center (in German).

When selecting the best treatment option, doctors primarily take the following factors into account:

• location, histological properties and molecular biological properties of the tumor
• the tumor stage (how much has the tumor grown into the tissue of the esophagus and how much have the cancer cells spread in the body?)
• the patient’s general state of health (what is the nutritional condition and are there pre-existing conditions?)
• the patient’s desires and needs

Localized tumor

Endoscopic therapy

For a tumor that is growing relatively superficially in the esophageal mucosa, an endoscopic resection is usually an adequate treatment. The surgery is similar to the inspection of the esophagus. The difference: the doctor pushes a small loop or special knives through the endoscope. These are used to completely cut the tumor away from the mucosa.

Alternatively, the doctor can use heat to destroy the tumor cells. The procedure is called ablation.

Locally advanced tumor

If the tumor has grown deeper into the tissue, many patients will need an operation. In the course of this, the doctors remove parts of the esophagus, but some patients will have their entire esophagus taken out.

Furthermore, chemotherapy or combined radiation and chemotherapy may be used as a treatment, depending on the situation also in addition to surgery.

Surgery

In an operation, the doctors remove the tumor and adjacent parts of the esophagus. If the tumor is extensive, the entire esophagus will be taken out.

If the tumor is located at the junction of the esophagus and stomach, it may be necessary to remove a section of the stomach or sometimes the entire stomach.

During the surgery, the doctors remove both the tumor and the adjacent lymph nodes. These are subsequently examined in a laboratory and give some indication of whether the cancer cells have spread beyond the tumor.

After the operation, the usual ingestion of food is not possible for several days. In this situation, patients normally receive their food via a thin tube (probe).

Pre- and post-operative radiation and chemotherapy

Patients with a locally advanced tumor can benefit from chemotherapy or combined radiation therapy and chemotherapy before the surgery.

The pre-treatment may shrink the tumor. That increases the likelihood of the doctors being able to completely remove it during the operation. A smaller tumor also means a less stressful surgery. The pre-treatment moreover reduces the risk of relapse after a successful operation.

For patients who have received chemotherapy but no radiation prior to surgery, the treatment is completed with further chemotherapy after the operation.

Some patients may require immunotherapy following surgery. It also reduces the risk of relapse.

Radiation and chemotherapy as an alternative to surgery

For some patients, the tumor in the esophagus cannot be surgically removed. Instead of an operation, a combination of radiation therapy and chemotherapy can be an option for them.

The same applies to patients who cannot cope with a complicated surgical procedure because of their general condition.

Metastases

If metastases have formed in more distant organs, a complete cure is no longer possible in most cases. There is usually no more surgical intervention in this scenario. Instead, treatment focuses on relieving the symptoms of the disease and providing the patient with the best quality of life possible.

Chemotherapy may prolong life in certain cases. So-called targeted drugs are also possible in this situation. Radiation therapy can moreover help relieve pain caused by the tumor.

You can find details about the treatment methods for esophageal cancer and associated side effects on the German Cancer Research Center’s Cancer Information Service website (in German).

Cancer can be very stressful. Most people with esophageal cancer need time after the treatment to get healthy again and resume a normal daily routine. Cancer patients therefore have the option of a targeted rehabilitation. 

Rehab is used to prevent or lessen the consequences of illnesses and therapy. For people in employment, the aims of rehabilitation also include returning to work. 

Rehab measures are tailored to the specific needs of patients with esophageal cancer. 

On one hand, rehab should improve physical discomfort and impairments. Possible measures are nutrition advice and nutritional therapy, physiotherapy and muscle-building training. Other rehab measures assist patients with handling the cancer diagnosis as well as possible emotional consequences like anxiety or depression. 

Anyone wishing to enter rehab can discuss it with the doctors treating them. They will certify the need for rehabilitation. Furthermore, hospital social services and local cancer counseling centers and health insurance providers or pension funds can answer questions about rehab. 

Further information about rehabilitation after oncological illnesses can be found on the German Cancer Research Center’s Cancer Information Service website (in German).

Most people affected by esophageal cancer still have to attend regular doctor or hospital appointments after treatment. The goal of these aftercare appointments is to check the patient’s health and do something about the aftermath of illness or therapy. Another aim is early detection of a possible relapse. 

A further aspect that doctors look for during aftercare is the nutritional condition of the patient. For example, patients experiencing difficulties in getting proper nutrition can receive nutritional counseling. If there is need for psychological counseling can also be determined during aftercare. 

As aftercare, patients are examined regularly after the end of therapy, initially at short intervals, then at longer ones. If the tumor was removed endoscopically, doctors perform inspections of the esophagus as part of aftercare. 

With an advanced illness, follow-ups replace aftercare. They take place at regular intervals or as needed. The aim is to maintain the patient’s quality of life for as long as possible using a therapy adapted to the symptoms. 

Nutrition is very important with esophageal cancer. The tumor can make it difficult to swallow food and cause pain during eating. And for many patients, the treatment also makes their nutritional situation worse. 

Nutrition before treatment

Even before the treatment, many patients have to first of all gain weight in order to be adequately prepared for the stressful therapy. If for instance difficulty swallowing has caused malnutrition, nutritional therapy in the form of high-calorie fluids or puree may be necessary. 

Nutrition after treatment

After the treatment, patients with esophageal cancer usually need nutrition advice to increase their body weight again long-term. In the consultation, they learn which foods they can tolerate and how they can make their diet balanced. 

When treating esophageal cancer, doctors from different fields work together closely. Hospitals with particular experience in treating patients with esophageal cancer can demonstrate this through certification. The German Cancer Society regularly checks the hospitals for compliance with certain professional requirements. 

You can find the addresses of the certified centers on the OncoMAP website.  

Do you have further questions about dealing with the condition in everyday life and additional support options? You can find information about this on the website of the Cancer Information Service of the German Cancer Research Center (in German).

For all questions about esophageal cancer, you can also make direct contact with Cancer Information Service doctors by dialing the freephone number (0800) 420 30 40 or by sending an e-mail to krebsinformationsdienst@dkfz.de.