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«Previous article | Next article»

Some sticking points in oesophageal cancer

Dr Heidi Furlong and Prof Thomas N. Walsh write about the importance of early diagnosis when it comes to oesophageal cancer and the challenges of treating it.

The three most striking things about oesophageal cancer are the rapidly increasing incidence, the delay in presentation for a tumour with such striking symptoms and the improving outcome. This year, more people will die of oesophageal and gastric cancer combined in Ireland than will die from breast cancer, but this is not reflected in the attention that they receive. There are many reasons for this, including the age profile of sufferers.

The increase in incidence of oesophageal adenocarcinoma has outstripped that of all other tumours, including lung and melanoma. There are many theories. The key predisposing factor is gastro-oesophageal reflux, which has increased in parallel to the increase in incidence of obesity.

One only has to look at old film footage of Ireland or America from the 1950s and 1960s to realise how our population has changed, from a time when obesity was the exception. Other theories include the use of nitrogen-based fertilisers in the food chain. It is noteworthy that oesophageal cancer is rare along the Mediterranean basin, suggesting that vitamin C has a protective role.

Problem of late diagnosis

Why is oesophageal cancer so often advanced at diagnosis? Research has shown that patients with oesophageal cancer are diagnosed late for three main reasons:
* They present late to their doctor;
* They are referred late to hospital;
* They are diagnosed late by hospitals.

In theory, oesophageal cancer should present early because its symptoms are so striking – food sticking on swallowing, dramatic weight loss and hiccups. When asked why they did not present earlier, the majority of oesophageal cancer sufferers in one study said they did not know that food catching on swallowing could be due to cancer.

Ironically, for many patients, the weight loss – which should set off alarm bells – is considered a blessing and a result of their weight-control attempts, which in fact may have amounted to nothing more than planning to diet or a trip to the gym.

Public awareness of oesophageal cancer is low and the awareness of its symptoms is even lower, especially when compared with breast or prostate carcinoma. One study showed that two thirds of patients had symptoms for more than three months and had over 6kg weight loss before presentation.

Surprisingly, while there are many bodies with a role in cancer management, no organisation has responsibility for educating the public to the earliest symptoms of cancer – when it can be treated cost-effectively with the best hope of cure. People have to learn on their own that certain symptoms have an ominous import. For this reason, Lollipop Day was established to highlight awareness of the symptoms of oesophageal cancer and appears to be having some impact.

Catching it earlier

How do we diagnose oesophageal cancer earlier? Too often, patients who give a history of dysphagia are not asked about weight loss. This is a crucial symptom because dysphagia accompanied by weight loss means oesophageal cancer until proved otherwise.

A trial of proton pump inhibitors (PPIs) is advocated for upper gastro-intestinal symptoms by many, but most patients will have some improvement in symptoms on a PPI, at least temporarily, and many will respond to the placebo effect of their visit to the doctor. Valuable time may be lost before it becomes apparent that symptoms have progressed.

All too often, patients referred with dysphagia are not prioritised. GPs should request an urgent endoscopy for all patients with dysphagia, especially those with recent weight loss, and hospital clinics should respond accordingly.

Even if the endoscopy is reported as normal, the GP should retain an open mind about persistent symptoms. Early oesophageal cancer can easily be missed at initial endoscopy, due to poor equipment or endoscopist inexperience, especially if the patient is un-co-operative or due to sampling error. Pathologists will report that only one or two biopsies of a ‘barn-door’ tumour may be positive for malignant cells. We advise at least 10 biopsies of any suspicious lesion and if suspicion persists, endoscopy should be repeated on PPIs a few weeks later.

We would also advocate a triple-assessment system, which has worked so well for breast cancer. That clinical assessment – which should include endoscopy – should be allied with imaging and biopsy. This should be repeated if suspicions persist.

Multidisciplinary management

The diagnosis and treatment of oesophageal cancer requires a large multidisciplinary approach. Multidisciplinary management centers on the surgical team, but the input is also vital of the radiologist, the gastroenterologist, the pathologist, the medical and radiation oncologists, the anaesthesiologist, the intensivist, the expert nursing team, a range of support physicians such as cardiac and respiratory physicians, and last but by no means least, the palliative care team who will unfortunately have to intervene in the majority of patients.

Expert endoscopy is crucial. Units must offer next-list endoscopy for dysphagia. Endoscopy is diagnostic, but only if carried out by experienced endoscopists with a high index of suspicion.

Endoscopy is also therapeutic when stenting or dilatation is performed to alleviate dysphagia prior to definitive treatment or as palliation for an advanced tumour. Finally, endoscopy is prognostic, particularly when used in conjunction with endoscopic ultrasound (EUS).

Staging

Staging of cancer of the oesophagus involves assessing the depth of penetration of the wall of the oesophagus, the involvement of lymph nodes, and whether there are systemic metastases. Currently, endoscopic ultrasound and computerised tomography (CT), and positron emission technology (PET) are the best we have.

It is humbling to have to acknowledge that the majority of patients who are staged as early and curable by resection will actually die of cancer, despite en-block tumour resection.

Treatment

Treatment depends largely on the stage of the tumour, patient fitness and patient preference and, it must be said, the philosophy of the management team. At least half of all patients have metastases at presentation and have a low likelihood of cure by current means.

Pragmatic palliative treatment is important as it may improve both the quality and the length of life. Symptom control can be achieved by stenting occluding tumours and by palliative chemotherapy, radiotherapy or a combination of both.

Patients with early tumours (T1 or T2) are currently offered surgery alone if they are fit and motivated for surgery. Paradoxically, they may also be the group most likely to respond completely to chemo-radiotherapy. Surgery alone is curative for the majority, but surgery is not without its cost in terms of acute morbidity and mortality and even long-term morbidity and mortality, especially from aspiration.

Treatment of fit patients with locally advanced disease is debated in the literature. Most units will now offer neo-adjuvant chemo-radiotherapy using 5-FU and Cisplatin and radiotherapy followed by surgery, particularly since long-term follow-up data is becoming available showing that this regimen improves long-term outcome.

The most striking benefit of pre-operative chemo-radiotherapy is that over one third of treated patients will have a complete pathological response and should not need surgery. We will now restage patients following pre-operative therapy and if the lumen is clear, we will inform patients over the age of 70 that they have a 75 per cent chance of not needing surgery. If disease emerges later on, surveillance endoscopy salvage oesophagectomy will provide a reasonable hope of cure.

Most young and fit patients are offered surgery after neo-adjuvant therapy, even if they have a complete luminal response on endoscopy, as it is difficult to detect minimal residual disease, even with the most advanced endoscopic and radiological techniques.

The future

There are many challenges for the future of oesophageal cancer treatment. The first is to increase awareness of the disease so that patients present at the first symptom, before the disease has spread. The second major challenge is to improve the rate of complete pathological response to neo-adjuvant therapy and novel agents are being developed.

A further challenge is to indentify in advance which patients are likely to have a complete response to neo-adjuvant therapy. Identifying complete responders who cannot benefit from oesophageal resection is also a challenge. The final challenge is to perform curative surgery with minimal morbidity. But we are making progress.

• Dr Heidi Furlong and Prof Thomas N. Walsh, RCSI Academic Centre, Connolly Hospital, Blanchardstown, Dublin.

Posted in Cancer on 14 April 2009
Tags: cancer

Tagcloud

abortion, accupuncture, ACE inhibitors, acne, ADHD, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anorexia, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, beta carotene, beta-blockers, bipolar disorder, birth, bleeding, blindness, blood pressure, body dysmorphic disorder, body mass, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cataracts, cervical cancer, chemotherapy, child psychiatry, children, cholesterol, clinical trial, clopidogrel, Clostridium difficile, cognitive behavioural therapy, colectomy, colic, colorectal cancer, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, Crohn's, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, DNA, Down's syndrome, eating disorders, echinacea, ECT, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, euthanasia, exercise, fat, fertility, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, haemodialysis, hearing, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, IBD, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, invasive candidiasis, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, Marfan syndrome, media, medical ethics, medical research, medication, meningitis, mental illness, metabolic syndrome, migraine, miscarriage, mortality rate, MRSA, multiple sclerosis (MS), NCHDs, nephrology, neurology, OAB, obesity, obstetrics, occupational health, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, practice, pre-eclampsia, pregnancy, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, radiotherapy, rectal cancer, reproductive health, research, resuscitation, rheumatoid arthritis, rheumatology, rhinitis, salt, SARS, schizophrenia, screening, seizures, self harm, sexual abuse, sexual health, sexually transmitted infections, SGA, sinusitis, skin cancer, sleep disorders, smoking, smoking ban, spinal injury, sports medicine, statins, stress, stroke, substance abuse, suicide, supplement, surgery, syncope, technology, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamins, weight, WHO, women's health, World Health Assembly

«Previous article | Next article»

Some sticking points in oesophageal cancer

Dr Heidi Furlong and Prof Thomas N. Walsh write about the importance of early diagnosis when it comes to oesophageal cancer and the challenges of treating it.

The three most striking things about oesophageal cancer are the rapidly increasing incidence, the delay in presentation for a tumour with such striking symptoms and the improving outcome. This year, more people will die of oesophageal and gastric cancer combined in Ireland than will die from breast cancer, but this is not reflected in the attention that they receive. There are many reasons for this, including the age profile of sufferers.

The increase in incidence of oesophageal adenocarcinoma has outstripped that of all other tumours, including lung and melanoma. There are many theories. The key predisposing factor is gastro-oesophageal reflux, which has increased in parallel to the increase in incidence of obesity.

One only has to look at old film footage of Ireland or America from the 1950s and 1960s to realise how our population has changed, from a time when obesity was the exception. Other theories include the use of nitrogen-based fertilisers in the food chain. It is noteworthy that oesophageal cancer is rare along the Mediterranean basin, suggesting that vitamin C has a protective role.

Problem of late diagnosis

Why is oesophageal cancer so often advanced at diagnosis? Research has shown that patients with oesophageal cancer are diagnosed late for three main reasons:
* They present late to their doctor;
* They are referred late to hospital;
* They are diagnosed late by hospitals.

In theory, oesophageal cancer should present early because its symptoms are so striking – food sticking on swallowing, dramatic weight loss and hiccups. When asked why they did not present earlier, the majority of oesophageal cancer sufferers in one study said they did not know that food catching on swallowing could be due to cancer.

Ironically, for many patients, the weight loss – which should set off alarm bells – is considered a blessing and a result of their weight-control attempts, which in fact may have amounted to nothing more than planning to diet or a trip to the gym.

Public awareness of oesophageal cancer is low and the awareness of its symptoms is even lower, especially when compared with breast or prostate carcinoma. One study showed that two thirds of patients had symptoms for more than three months and had over 6kg weight loss before presentation.

Surprisingly, while there are many bodies with a role in cancer management, no organisation has responsibility for educating the public to the earliest symptoms of cancer – when it can be treated cost-effectively with the best hope of cure. People have to learn on their own that certain symptoms have an ominous import. For this reason, Lollipop Day was established to highlight awareness of the symptoms of oesophageal cancer and appears to be having some impact.

Catching it earlier

How do we diagnose oesophageal cancer earlier? Too often, patients who give a history of dysphagia are not asked about weight loss. This is a crucial symptom because dysphagia accompanied by weight loss means oesophageal cancer until proved otherwise.

A trial of proton pump inhibitors (PPIs) is advocated for upper gastro-intestinal symptoms by many, but most patients will have some improvement in symptoms on a PPI, at least temporarily, and many will respond to the placebo effect of their visit to the doctor. Valuable time may be lost before it becomes apparent that symptoms have progressed.

All too often, patients referred with dysphagia are not prioritised. GPs should request an urgent endoscopy for all patients with dysphagia, especially those with recent weight loss, and hospital clinics should respond accordingly.

Even if the endoscopy is reported as normal, the GP should retain an open mind about persistent symptoms. Early oesophageal cancer can easily be missed at initial endoscopy, due to poor equipment or endoscopist inexperience, especially if the patient is un-co-operative or due to sampling error. Pathologists will report that only one or two biopsies of a ‘barn-door’ tumour may be positive for malignant cells. We advise at least 10 biopsies of any suspicious lesion and if suspicion persists, endoscopy should be repeated on PPIs a few weeks later.

We would also advocate a triple-assessment system, which has worked so well for breast cancer. That clinical assessment – which should include endoscopy – should be allied with imaging and biopsy. This should be repeated if suspicions persist.

Multidisciplinary management

The diagnosis and treatment of oesophageal cancer requires a large multidisciplinary approach. Multidisciplinary management centers on the surgical team, but the input is also vital of the radiologist, the gastroenterologist, the pathologist, the medical and radiation oncologists, the anaesthesiologist, the intensivist, the expert nursing team, a range of support physicians such as cardiac and respiratory physicians, and last but by no means least, the palliative care team who will unfortunately have to intervene in the majority of patients.

Expert endoscopy is crucial. Units must offer next-list endoscopy for dysphagia. Endoscopy is diagnostic, but only if carried out by experienced endoscopists with a high index of suspicion.

Endoscopy is also therapeutic when stenting or dilatation is performed to alleviate dysphagia prior to definitive treatment or as palliation for an advanced tumour. Finally, endoscopy is prognostic, particularly when used in conjunction with endoscopic ultrasound (EUS).

Staging

Staging of cancer of the oesophagus involves assessing the depth of penetration of the wall of the oesophagus, the involvement of lymph nodes, and whether there are systemic metastases. Currently, endoscopic ultrasound and computerised tomography (CT), and positron emission technology (PET) are the best we have.

It is humbling to have to acknowledge that the majority of patients who are staged as early and curable by resection will actually die of cancer, despite en-block tumour resection.

Treatment

Treatment depends largely on the stage of the tumour, patient fitness and patient preference and, it must be said, the philosophy of the management team. At least half of all patients have metastases at presentation and have a low likelihood of cure by current means.

Pragmatic palliative treatment is important as it may improve both the quality and the length of life. Symptom control can be achieved by stenting occluding tumours and by palliative chemotherapy, radiotherapy or a combination of both.

Patients with early tumours (T1 or T2) are currently offered surgery alone if they are fit and motivated for surgery. Paradoxically, they may also be the group most likely to respond completely to chemo-radiotherapy. Surgery alone is curative for the majority, but surgery is not without its cost in terms of acute morbidity and mortality and even long-term morbidity and mortality, especially from aspiration.

Treatment of fit patients with locally advanced disease is debated in the literature. Most units will now offer neo-adjuvant chemo-radiotherapy using 5-FU and Cisplatin and radiotherapy followed by surgery, particularly since long-term follow-up data is becoming available showing that this regimen improves long-term outcome.

The most striking benefit of pre-operative chemo-radiotherapy is that over one third of treated patients will have a complete pathological response and should not need surgery. We will now restage patients following pre-operative therapy and if the lumen is clear, we will inform patients over the age of 70 that they have a 75 per cent chance of not needing surgery. If disease emerges later on, surveillance endoscopy salvage oesophagectomy will provide a reasonable hope of cure.

Most young and fit patients are offered surgery after neo-adjuvant therapy, even if they have a complete luminal response on endoscopy, as it is difficult to detect minimal residual disease, even with the most advanced endoscopic and radiological techniques.

The future

There are many challenges for the future of oesophageal cancer treatment. The first is to increase awareness of the disease so that patients present at the first symptom, before the disease has spread. The second major challenge is to improve the rate of complete pathological response to neo-adjuvant therapy and novel agents are being developed.

A further challenge is to indentify in advance which patients are likely to have a complete response to neo-adjuvant therapy. Identifying complete responders who cannot benefit from oesophageal resection is also a challenge. The final challenge is to perform curative surgery with minimal morbidity. But we are making progress.

• Dr Heidi Furlong and Prof Thomas N. Walsh, RCSI Academic Centre, Connolly Hospital, Blanchardstown, Dublin.

Posted in Cancer on 14 April 2009
Tags: cancer