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What we need to do to win the battle against oesophageal cancer
Shanthi couldn’t believe what the doctor had told her few minutes earlier. How was it possible? Perhaps the doctor was trying to scare her because she didn’t get the endoscopy done as soon as he had advised one. “I could accept this if I was over 60, a smoker and drinker. But I am only 28, have no habits and no family history. How then did it happen?” she wondered.

Shanthi worked as a receptionist at the clinic of a leading doctor in a metro. It all began when she went to consult her doctor after experiencing a “Sticky” feeling in the chest when she was having a non–vegetarian meal. The feeling passed when she drank water. She felt okay after that, but the sensation, the sticky feeling, and the need to drink water to “Push” the food down continued for a few weeks.

Scary diagnosis
The doctor advised an endoscopy the next day, but she was not convinced about the need. Instead she modified her diet from non–vegetarian to vegetarian, from chapatti to idly and dosa. She went back to the doctor only when she found even these were difficult to swallow. This time she volunteered to have the endoscopy done.

The endoscopy and tissue examination led to a diagnosis that understandably shook her. The doctor reported that there was a possibility that she had cancer of the food pipe. A biopsy was needed to confirm the nature of the disease. The biopsy report came and, to her horror, the doctor was correct. It turned out to be oesophageal cancer.

After a series of investigations to assess the extent of spread and the status of other systems in her body and finally told her that the cancer could be removed by surgery, but it was a major one which could last a few hours. Recovery might take a few weeks. But he was optimistic that she would be able to eat and that she would have to undergo radiation therapy and chemotherapy after surgery to prevent or avoid recurrence of the disease.

The treatment plan gave her renewed courage. She went though all three modalities of treatment though she found it hard physically…mentally and emotionally. Luckily, she could get back to her normal diet and do her regular work.

There are many like Shanthi who don’t go to the doctor when they develop similar symptoms, just because they are fearful that they could be suffering from “Oesophageal cancer”. This type of cancer affects the 25 cm long food pipe, which transports the food from mouth to stomach. But it can be very harmful if those symptoms are ignored, as oesophageal cancer is among the “Top five” cancers affecting the Indian population.

Strangely enough, the oesophageal cancer that affects the Indian or Asian population is different from the one affecting the western population. Almost everything is different: from the cause, the way it presents, the type of treatment, and the way it responds. The only common factors are smoking and drinking apart from genetic factors.

High incidence
India falls within the “Asian oesophageal cancer belt” where oesophageal cancer is high (a few pockets in China have the highest incidence). The majority of the cancers are, pathologically, squamous cell carcinoma and, in most situations, the first manifestation is a sticky feeling in the throat or difficulty in swallowing. Ironically, the disease is usually advanced by this time.

Thanks to technological advances, it is possible not only to make an accurate diagnosis, but to precisely assess the extent of spread. This helps in planning the right treatment. The technical expertise available – gastrointestinal and cardiothoracic surgeons, medical gastroenterologists and oncology surgeons, radiation oncologists and medical oncologists – makes it possible for them to work as a team, as the successful outcome of oesophageal cancer warrants a multidisciplinary approach. This is referred to as “Multi–modality therapy”.

Once the doctor suspects oesophageal cancer, a video endoscopy is done. This displays the cancer on a video screen. Its extent within the food pipe can be measured and biopsy is done to find out the type of cancer to determine the treatment modality. Unfortunately, many people are afraid of an endoscopy. It is not uncommon to find patients visiting multiple doctors driven by the ‘Hope’ that somebody would treat them without resorting to an endoscopy. They fail to realise that endoscopy is their saviour. Today, it is possible to assess the local extent of involvement and spread into adjacent lymph nodes by using advanced endoscopic ultrasound equipment.

In certain situations the doctor may order a Barium swallow before doing the endoscopy. Once the cancer is confirmed, CT scan of the chest and abdomen is done to find out the possible involvement of adjacent structures and the spread to the distant organs. Sometimes, a bronchoscopy, or passing a tube into the respiratory passage, is done to determine the possible involvement or spread to the respiratory tract. All these tests detect lesions that have reached six mm or 10mm in size. Scientific advances have made it possible to assess the increased metabolic activity of the cancer cells using Positron Emission Tomography, or PET scan. Unfortunately, this test is not available everywhere.

It is important to assess the functional status of other systems like the heart and lung with the help of ECG, Echocardiogram and Pulmonary Function Tests as most patients are over 60, are smokers and are used to alcohol. Any type of treatment modality warrants assessment of liver and kidney function as well as nutritional status.

After the assessment, the team will decide whether the patient is a candidate for surgery, Radiotherapy, Chemotherapy or combined modality of treatment. Contrary to many other cancers, the expectation of both the patient and the doctor revolves around the basic human need: to eat normal food as long as the patient is alive. Invariably, the patient’s first priority is eating followed by long life, but doctors are happier if they can achieve both.

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Treatment
When the disease is confined to the oesophagus and has not infiltrated vital structures, it is managed by surgical removal of the oesophagus. This is then normally replaced by the stomach, as replacement organ. In some situations when the stomach is not available or involved by the cancer even that is removed and both the organs are replaced by a part of the large intestine called as Colonic reconstruction or Coloplasty. In select situations, the team may decide on giving chemotherapy and radiotherapy to reduce the size of the tumour and then operate, and the chemoradiotherapy continued after surgery to prevent recurrence. Sometimes, the patient is advised chemotherapy and radiotherapy as definitive therapy avoiding surgery.

When the patient’s general condition is very bad and nutritionally depleted, none of these options may be possible. The doctors can still help by placing a stent, which is a tube, across the tumour. This helps the patient eat through the normal passage.

When the disease spreads to adjacent structures, pain can be a predominant symptom. This is essentially addressed by the palliative care physicians who provide medical support in terms of pain relief and help handle emotional problems. They even visit patients at home as the aim is to let them die with dignity and without suffering.

Routine screening is done in few countries but is difficult in country like India, but it is at least possible to detect the disease at a manageable or treatable stage, if the patient approaches the doctor at the first symptom. Sadly, even today, many do not come forward in time. An evasive group tries to avoid endoscopy. The pessimistic group tries to avoid surgery. But the model should be the optimist group, represented by patients like Shanthi. Although she initially avoided the endoscopy, she underwent the entire treatment course and got back to normal Not only is she normal now, she is able to spend time with people suffering from oesophageal cancer explaining the types of treatment, problems and therapy options as also overcoming emotional depressive episodes. In short, she functions as an ambassador.

There are many like Shanthi who are willing to offer their help to sufferers. These former patients, their kith and kin, the doctors who helped them, philanthropists and volunteers have come together and formed the “Oesophageal Patients Support Organisation (EPSO)”. The members are available to help with answers to doubts and help them in times of need.

What is the oesophagus?
The oesophagus is a 25 cm long tubular structure, which starts in the neck, traverses the entire chest, hugged by all important structures such as the heart, respiratory passage, the lungs on either side, the major blood vessels and the nerve responsible for speech.

Then it enters the abdomen to join the stomach, which is called the oesophagogastric junction. The food pipe “transports” food from the mouth to the stomach and any obstacle or block here manifests as difficulty in swallowing. Depending upon the severity of the obstruction, the difficulty in swallowing may be of different degrees.

Who can fall victim?
Generally, oesophageal cancer is found in people over 60 years of age.

It is common among those who use tobacco in some form or other and people who drink. The incidence increases if the person has been smoking and drinking for many years.

People who don’t eat nutritious food, malnutrition is considered an important cause of oesophageal cancer. Studies have shown deficiencies of vitamins A, D, E, and K, and minerals like Zinc, Selenium and Molybdenum can also contribute to the risk.

Drinking boiling hot coffee or tea adds to the problem.

It affects men more commonly than women, possibly because more men smoke and drink. In women who have been diagnosed to have oesophageal cancer, there were fewer with drinking and smoking habits (although many don’t reveal these facts during the initial visits).

Sometimes, there can even be a genetic factor that is when it can occur at earlier age group.

Symptoms
Often the doctor may suspect the possibility of oesophageal cancer just by listening to the patient’s history. There may not be any clinical finding, hence it is described as a “disease of symptoms and few or no signs”.

Typically, the patients present with progressive difficulty in swallowing. Initially the problem begins with solids and gradually extends to soft solids, semi–solids, and liquids. Ultimately, the patients may not even be able to swallow their own saliva.

Other symptoms could be due to the spread to adjacent structures.

Infiltration or spread to the nerves that supply the vocal cord can produce change in voice.

Stasis of food in the food pipe can lead to aspiration of food content into the respiratory passage, producing violent bouts of cough.

Infiltration of structures behind the food pipe can produce back pain.

Spread into the respiratory passage can lead to a condition called tracheoesophageal fistula, which can be described as communication between the respiratory passage and oesophagus. In this condition, the patients develop violent bouts of cough when they eat or drink, and even when they attempt to swallow their own saliva.

Spread into lymphatics can show up as swellings in the neck that can be felt by the doctor, and distant spread can affect the lungs and ultimately any organ in the body. Over a period of time the patient loses weight and becomes malnourished.

The writer is a gastrointestinal surgeon based in Chennai.
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Source: http://www.hindu.com