OESOPHAGEAL CANCER

Further Information about Oesophageal Cancer

Certain factors may increase your risk of developing oesophageal cancer, including:

• Age: Most people diagnosed with oesophageal cancer are over 50 years old.

• Gender: Men are more likely to develop oesophageal cancer than women.

• Tobacco use: Smoking is a major risk factor for oesophageal cancer.

• Alcohol use: Heavy drinking increases the risk, especially when combined with smoking.

• Gastroesophageal reflux disease (GORD): Chronic acid reflux can damage the oesophagus and increase the risk of adenocarcinoma.

• Barrett’s oesophagus: A condition where the cells lining the lower oesophagus change "type", due to chronic acid exposure. Over time, this chronic "injury" from acid exposure can lead to the cells abnormally growing, causing cancer

• Obesity

• Radiation exposure

• Family history: A family history of oesophageal cancer or other cancers may increase your risk. Some inherited conditions such as Cowden Syndrome or Peutz-Jeghers Syndrome (PJS) can cause oesophageal cancer

Oesophageal cancer is slow growing and often insidious in its presentation. In the early stages there may not be any symptoms. Symptoms are seen as the tumour grows.

Common symptoms include:

• Difficult or painful swallowing (dysphagia)

• Unexplained weight loss

• New heartburn

• Reflux that does not go away

• Hoarseness or persistent cough

• Feeling of food getting stuck in the chest

• Fatigue

• Vomit that has blood in it

• Black or bloody stools

A combination of tests that are performed will help firstly diagnose, then "stage" oesophageal cancer.

Staging is a process of performing tests that help understand the extent of the cancer and how far it has spread, to inform on the most appropriate treatment strategy.

The common tests & procedures performed to diagnosis and stage oesophageal cancer include:

• Endoscopy: The most common investigation for diagnosing oesophageal cancer. An endoscope (A thin tube with a camera is inserted through your mouth) is used to visualise the inside of the oesophagus and stomach.
  At the same time a small amount of tissue is removed (a biopsy) can be taken and examined by a pathologist

• Endoscopic ultrasound (EUS): Like an endoscopy, an endoscope with an ultrasound probe on its tip, is inserted into the oesophagus. This allows for visualisation of the tumour spread through the layers of oesophageal wall, and also evaluate the lymph nodes nearby (these can be sampled with a fine needle).
  Not every patient needs an EUS.

• CT/PET scans: Highly specialised CT scans that take detailed images of your chest, abdomen and pelvis to assess the location of the tumour and to check if the cancer has spread to other parts of the body.

• Blood tests: Including blood tests, to assess general health, check for low red cells counts, kidney and liver function testing, iron levels  

• Laparoscopy: Selectively used to assess the inside of the abdominal cavity as part of the "staging" process of the cancer

• Fitness testing: An operation for oesophageal cancer, as well as the chemotherapy, is physically demanding on patients. Prior to embarking on curative treatment, testing of your heart (via ultrasound scans, sometimes when exercising) and lungs (lung function testing) is often performed. This is to ensure that it is safe to proceed with such treatments.

Receiving a diagnosis of oesophageal cancer can understandably lead to feelings of distress, shock, confusion, and concern. You may find it beneficial to discuss your diagnosis and potential treatment options with a specialist doctor.

Dr. Matthew Stokes & Dr. Josh Hammerschlag prioritise urgent appointments for new cancer diagnoses, ensuring that you and your family have the opportunity to thoroughly discuss the diagnosis and available treatment options, as soon as possible.

Treatment for oesophageal cancer depends on the stage of the disease, your general health, and other individual factors.

Stages I-III for oesophageal cancer relate to increasing degrees of localised (but not metastatic) cancer, that have spread into adjacent lymph glands/nodes, but not to more distant parts of the body. In this situation, curative treatment is often multi-modal, utilising surgery, chemotherapy and or radiotherapy.

Stage IV disease unfortunately refers to "metastatic" disease, whereby secondary deposits of cancer (metastases) have been seen in organs such as the liver, lung, bone or inside the abdominal cavity. In this situation, surgery is not possible, and treatment is typically aimed to slow the growth of the tumour, and control symptoms, using chemotherapy, immunotherapy, radiotherapy, and endoscopic options such as stents.

The main treatment options are:

• Surgery: The removal of part or all the oesophagus (oesophagectomy). An oesophagectomy is the most common form of curative treatment, when the patient is fit enough to under the surgery and the cancer is localised to the oesophagus (and adjacent lymph nodes) only. See below for further details.

• Radiation therapy: High-energy rays are used to kill cancer cells or shrink tumours. This can be used alongside surgery or as a standalone treatment for advanced cancer

• Chemotherapy: Cancer-fighting drugs that are either taken orally or given through an IV. Chemotherapy is often given before surgery (neoadjuvant) to shrink the tumour and slow its growth, after surgery (adjuvant) to kill any remaining cancer cells, or as the main treatment for advanced cancer.

The standard regimen of chemotherapy currently for oesophageal, Gastro-oesophageal junction, and Gastric Cancer in Australia, is FLOT4 Chemotherapy.
FLOT4 consists of 4 chemotherapy agents (Fluoruracil, Leucovorin, Oxaliplatin and Docetaxel), given in 4 cycles, 2 weeks apart (8 weeks total), before and after an oesophagectomy/gastrectomy. FLOT4 became the “standard of care” after the FLOT4 & ESOPEC Trials showed significant improvement in overall survival when compared to other chemo- and chemo-radiotherapy regimens.

• Targeted Therapy & Immunotherapy: Treatment that helps the immune system recognise and destroy cancer cells. Some oesophageal and gastric tumours display specific “markers” that can be targeted with medications before, or after surgery. This includes HER-2 (using Trastuzumab/Herceptin) and PDL-1 (using PDL-1 inhibitors e.g. Nivolumab, Prembrolizumab). These can be given before or after surgery, or in the advanced, metastatic setting, alongside chemotherapy. There is a lot of research currently investigating the role of targeted therapy & immunotherapy in the management of non-metastatic, locally advanced oesophageal cancer, prior to surgery.

• Palliative care: For advanced cancers, palliative treatments can help manage symptoms and improve quality of life. These may include treatments to ease swallowing difficulties, manage pain, or relieve discomfort, such as medications, chemotherapy, immunotherapy, and oesophageal metallic stents to facilitate eating and drinking

• Nutrition: Maintaining proper nutrition during treatment for oesophageal cancer is crucial. Many patients have difficulty eating before their diagnosis and may lose weight. Depending on your ability to eat, weight loss, and nutritional status (assessed by specialised UGI dietitians), a feeding tube (either nasogastric/nasojejunal or surgically placed jejunostomy) might be recommended before starting chemotherapy and possibly during surgery to support post-surgery nutrition. All patients considering curative treatment will consult a specialist dietitian.

Surgery is the main curative treatment for localised (non-metastatic) oesophageal cancer. Often for early Stage I disease, surgery alone can be curative. For more localised advanced Stage II and III, combining surgery with chemotherapy or chemo-radiotherapy improves outcomes.

An oesophagectomy is a significant operation that should only be performed by specialist trained oesophago-gastric surgeons who have undertaken formal training in the procedure and the care of these patients.

An oesophagectomy is an operation that involves operating in the abdomen, the chest and sometimes, the neck. The most common type of oesophagectomy is an Ivor Lewis Oesophagectomy. In this procedure, most of the oesophagus is removed, along with the upper portion of the stomach. In addition, the adjacent lymph nodes in the chest and upper abdomen are also removed at the same time. The remaining stomach is then shaped into a tube, and pulled through the diaphragm, and connected to the remaining upper oesophagus, either in the chest (Ivor Lewis Oesophagectomy) or in the neck (3 Stage McKeown Oesophagectomy).

Wherever possible, we will utilise minimally invasive techniques (laparoscopic/robotic) to perform part, or all the procedure. Minimally invasive technique involves making small, <1cm incisions on the abdomen & right chest, to gain access into the abdominal & chest cavity to perform the procedure. The surgical approach best suited to your individual situation will be discussed with you by your surgeon.

Dr. Stokes has received specialist training in all types of oesophagectomy, including open, laparoscopic, and robotic surgical techniques. In 2024, he completed an international fellowship in Oesophago-gastric cancer at The Royal Infirmary Edinburgh.