Cancer Of The Esophagus |
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Esophagus cancer is a terrible disease and it is becoming more and more common in this country. In fact, since 1970, the incidence of cancer of the esophagus has risen more rapidly than any other cancer in the United States - about a 700% rise in the last three decades. In the 1990's esophagus cancer has become the 8th most common cancer worldwide.
The reason for this sudden upsurge is not clear, but it is known that many of these cases are preceeded by damage and ulceration in the lower esophagus due chronic acid reflux, or heartburn. Even though over 60 million Americans feel heartburn at least once a month, the problem is not really taken seriously. Of course, occasional mild heartburn is not serious. But many individuals live with severe heartburn on a daily basis and think that is just the way it is supposed to be. They go to the neighborhood drug store and purchase antacids in the giant economy size. They always have Tums or Rolaids in their pocket and often awaken during the night and take a dose of Maalox. Nowdays, they use Pepcid AC or Tagamet HB, or one of the many over-the-counter acid suppressors. In fact, Americans spend over He¹s not alone. In fact, Americans spend almost $15 billion a year on medications to treat heartburn.Still they have symptoms, but put off seeing their doctor. Not everyone with heartburn at risk for cancer. But when it occurs, it is almost always fatal. Over 12,000 Americans a year get this form of cancer. The more severe the heartburn and more frequent symptoms, the higher the risk of cancer. |
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| What Are The Symptoms Of Esophagus Cancer? |
| Unfortunately, there are no "warning symptoms." Esophagus cancer is a lot like colon cancer; symptoms only occur late in the course of the disease. The most common symptom of cancer of the esophagus is difficulty swallowing, also called dysphagia. At first, the episodes are mild and infrequent. The patient notes some resistance to swallowing, but the food eventually does makes its way into the stomach. As the cancerous growth gradually enlarges and blocks the passageway, the symptoms become more frequent and more severe. Some patients can only swallow liquids or semisolid food. Others present to the emergency room with a piece of solid food such as meat firmly lodged in their esophagus. They are unable to even swallow their saliva and are seen in the waiting room with a spit cup. As the cancer advances, pain may be felt when swallowing or a dull pain may be felt behind the breastbone. |
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| How is Esophagus Cancer Diagnosed? |
| If you have difficulty swallowing, it does NOT mean that you have cancer of the esophagus. In fact, most patients with this complaint have a hiatal hernia or non-cancerous stricture which blocks the passage of food. It is your doctor's job to determine the underlying cause of your symptoms. If you complain about difficulty swallowing, tests will be necessary to evaluate your condition. Testing will usually begin with a medical history and physical exam. The doctor will want to know how often and under what circumstances the problem occurs. |
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| Most cases will require a "scope" test of the upper digestive system. Also known as a gastroscopy or EGD exam, this simple test is quickly and painlessly performed using a mild sedative. A thin flexible sterilized tube is passed through the mouth and down into the esophagus and stomach. A tiny color video camera within this instrument allows the doctor to directly examine the esophagus, stomach, and upper small intestine. When necessary, photographs and biopsies can be obtained for later review. |
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| X-ray studies are often used. Barium x-rays may be requested to view the esophagus during the act of swallowing. A CT scan or MRI can help determine if the cancer has broken through the wall and spread beyond the esophagus. A special Endoscopic Ultrasound is also sometimes done to help stage the disease. |
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| Less commonly, the doctor may request an esophageal manometry study which measures the strength and coordination of the esophageal contractions as well as the pressure of the special "trapdoor valve" between the stomach and esophagus. By performing these tests the doctor can most accurately determine exactly what is causing difficulty swallowing and what treatment will be necessary. |
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| What Are The Stages Of Esophagus Cancer? |
| The chance of recovery (prognosis) and choice of treatment depend on the stage of the cancer (whether it is just in the esophagus or if it has spread to other places) and the patient's general state of health. For treatment purposes, there are five possible stages of esophagus cancer: |
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| Stage 0 (carcinoma in situ) This is a very early cancer. In fact, the cancer cells are found only in the top layer of inner wall of the esophagus. |
| Stage I Cancer is found in only a small part of the esophagus and has not spread to nearby tissues, lymph nodes, or other organs. |
| Stage II Cancer is found in a large portion of the esophagus and has spread to all sides of the esophagus, and may have spread to local lymph nodes, but has not spread to other tissues. |
| Stage III Cancer has spread to tissues or lymph nodes near the esophagus, but has not spread to other parts of the body. |
| Stage IV Cancer has spread to other parts of the body such as the liver or lung. |
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| How is Esophagus Cancer Treated? |
| Treatment is individualized for each a patient. Regardless of the stage, all patients can benefit from some form of treatment. Obviously, the more advanced the disease, the less likely a cure. Even then, treatment can provide relief of symptoms and slow the progression of the disease. Four kinds of treatment are commonly used. They may be used individually, or most commonly, in combination. |
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| Surgery (taking out the cancer in an operation) |
| Radiation therapy (using high-dose x-rays to kill cancer cells) |
| Chemotherapy (using drugs to kill cancer cells) |
| Endoscopic therapy to destroy some of the tumor with possible stent placement |
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Surgery is the most common treatment for cancer of the esophagus. The esophagus is removed and the stomach is connected to the throat so that the patient can still swallow. Sometimes a part of the intestine is used to make the connection. The doctor may also remove lymph nodes around the esophagus and look at them under a microscope to see if they contain cancer.
Radiation therapy uses x-rays to kill cancer cells and shrink tumors. This is sometimes used before surgery to shrink the tumor before surgery. When surgery can't be performed, radiation therapy is used to slow down progression of the tumor. This is called palliative therapy. Treatment is given in daily small doses over six to eight weeks.
Chemotherapy uses medications to kill cancer cells. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells throughout the body.
In the most advanced cases, gastroscopy, the scope test mentioned above, can sometimes be used to destroy part of the tumor and reopen the passageway. This does not remove the tumor, but does allow the patient to at least swallow a semisolid diet. As the tumor grows, the treatments have to be repeated. Sometimes a plastic covered metal wire stent is placed across the tumor to help keep the passageway open. This is only done in patients who are terminal since the stent can't be removed and does involve some risk. Eventually, it becomes a losing battle and the cancer wins. It is a depressing situation, but the procedure does help make the last few months more comfortable. |
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| Can Esophagus Cancer Be Prevented? |
| There is no guaranteed way to prevent esophagus cancer. But you can minimize your risk by avoiding the three main risk factors: |
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| Tobacco |
| Alcohol |
| Heartburn |
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| Men get this kind of cancer three times more often than women. Esophageal cancer is three times more common among African Americans than whites. Those at highest risk are individuals who smoke and drink regularly and complain of chronic heartburn. They can reduce their risk by stopping all tobacco, drinking in moderation, and aggressively evaluating and treating heartburn. Those that have heartburn more than once a week or severe heartburn, should consult with their physician. Any one who has noted difficulty swallowing, should be referred for a full evaluation. |
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| Heartburn and Barrett's Esophagus |
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If you stop and think about it, is amazing that your stomach does not digest itself. The powerful hydrochloric acid inside your stomach is strong enough to liquify a piece of meat that you swallow. Your stomach is also made out of meat, or muscle tissue. Why doesn't it digest itself? Actually, the stomach is protected from its own acid by a special mucous layer that covers the inner lining. Unfortunately, the esophagus didn't get such a "raincoat." Instead, there is a one-way "valve" called the Lower Esophageal Sphincter. This is like a tiny trapdoor between your foodpipe and stomach. It lets the food go down into the stomach pouch, but then closes to prevent the backsplash of acid onto the delicate esophageal lining.
When the valve malfunctions, acid splashes (reflexes) upward and begins to damage the lower part of the esophagus. With repeated exposure, ulcers may form. This is called Gastroesophageal Reflux Disease, or GERD.
The tissue that lines the esophagus is different than that covering the stomach. When the esophagus ulcers heal, you would expect the normal esophagus tissue to patch the spot. Sometimes, for reasons unknown, the stomach lining creeps upward into the lower esophagus and covers the spot. Now you have stomach lining inside the lower esophagus. This condition, called Barrett's Esophagus, is permanent even after the ulcers heal. It is not really a problem, except that the risk of cancer of the esophagus is higher is patients with Barrett's esophagus - 30 to 60 times than the general population.
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| While esophagus cancer can sometimes develop directly, Barrett's esophagus usually develops into cancer via a five-step process that permits time for early diagnosis and intervention. The progression is for patients to progress from: |
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| Esophagitis (GERD) |
| Barrett's Esophagus |
| Low-grade Dysplasia (pre-cancer) |
| High-grade Dysplasia (almost cancer) |
| Carcinoma-In-Situ Stage 0 ( a few early confined cancer cells) |
| Adenocarcinoma (Cancer Stages I to IV) |
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Patients with GERD and those who have gone on to develop Barrett's changes need aggressive therapy and close monitoring to reduce their risk of cancer. The best approach is to prevent Barrett's in the first place by treating chronic heartburn avoiding all tobacco, and only drinking in moderation.
Not everybody who experience heartburn needs to see their doctor. But if the symptoms are frequent, severe, or progressive, seek medical attention. While new and improved over-the-counter drugs like Pepcid AC and Tagamet HB have helped some heartburn sufferers find relief, many experts fear that the medications may be masking symptoms of more serious problems. While the drugs can be helpful for people with occasional heartburn and indigestion, a person should seek a doctor¹s help if symptoms last two weeks or more, experts say. If you have heartburn, ask yourself these questions: |
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| Do you take antacids two or more times a week? |
| Do you take heartburn medicine(s) other than antacids? |
| Does your heartburn interfere with your daily activities? |
| Do these symptoms often occur after meals? |
| Do these symptoms interfere with your sleep? |
| Do you find that your medicine only relieves your symptoms for short periods of time? |
| Do you have difficulty swallowing? |
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| Follow Up |
| After treatments are completed, patients need to remain under surveillance for possibility that the cancer may come back. This is termed "reoccurrence." Follow-up should be scheduled on a regular basis. The frequency of follow-up will depend on the condition of the patient and his/her disease. In each follow-up visit, patients are examined and a chest x-ray is normally obtained every few months. A CT scan of chest, bone scan and endoscopy may be repeated periodically. |
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| More Information |
| More information about esophageal cancer can be found at the American Cancer Society's Esophageal Cancer Resource Center on the Internet. |
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