A Bitter Pill to Swallow Experts from The James explain risks and treatments for esophageal cancer

By Claire Miller

D’Souza says. “However, if by chance someone is getting an upper endoscopy for, say, acid reflux or things like that, then you pick up early changes in the esophagus and you detect esophageal cancer early – like, early stage one –then there are these promising endoscopic techniques.”

The endoscopic techniques are not considered surgery; they’re performed with an endoscope, a camera that goes down into the esophagus. Cancerous nodules found this way can be removed with the endoscope. This technique is now the standard of care for early-stage esophageal cancer, but not every surgeon is able to perform the procedure, and it’s typically done in places with expertise in treating esophageal cancer.

APRIL IS ESOPHAGEAL Cancer Awareness Month.

Out of all the types of cancers diagnosed each year in the U.S., just 1 percent are esophageal cancers.

According to the American Cancer Society, about 21,560 new cases will be diagnosed in 2023. It’s estimated there will be 16,120 deaths, so, while esophageal cancer isn’t one of the most common, it is one of the more deadly.

“(It’s) unlike breast cancer, where you can get a mammogram, or colon cancer, where you can get a colonoscopy, to get screened for those cancers,” says Desmond D’Souza, a thoracic surgeon at The Ohio State Comprehensive Cancer Center – James, “with esophageal cancer, there’s really no screening.”

This makes it difficult to catch in the early stages and increases its morbidity.

“The vast majority of (cases) are in later stages of cancer, in which case early therapies, which are very effective, are not an option because the cancer has already progressed,”

One of the reasons esophageal cancer tends to be missed in the early stages is because there often aren’t any symptoms until the tumor is large enough that it’s blocking off the esophagus and the patient has trouble swallowing. Other warning signs are unintentional weight loss, chest pain, hoarseness, blood in the stool and vomiting blood.

Not all risk factors can be prevented, such as those related to age and sex, but there are lifestyle changes that can be addressed or monitored.

For those at higher risk – people with obesity, long-standing acid flux disease or Barrett’s esophagus, in which acid reflux causes cells in the inner lining of the esophagus to change from normal to precancerous cells – upper endoscopies at regular intervals are recommended.

Esophageal cancer affects men more than women; the lifetime risk is 1 in 125 for men and 1 in 417 in women, according to the American Cancer Society.

There are two main types of esophageal cancer: adenocarcinoma and squamous cell carcinoma. Adenocarcinoma is seen in the bottom half of the esophagus, while squamous cell tends to occur in the upper half.

In the U.S., adenocarcinoma is more common. The primary risk factors are acid reflux disease and obesity, while the risk factors for squamous cell carcinoma are smoking, drinking alcohol and high salt diets, says Ning Jin, a medical oncologist on the esophageal cancer team at The James.

Most patients have locally advanced tumors, and the typical treatment requires chemotherapy and radiation. A recent advancement in medical treatment is adjuvant immunotherapy, which is additional therapy after surgery.

“Immunotherapy is offering great promise in treating esophageal cancer patients who underwent chemo radiation followed by surgery, and offers benefits in terms of prolonging so-called progression free survival, especially for patients with esophageal squamous cell carcinoma,” Jin says.

Esophageal cancer has historically been treated with a combination of chemotherapy, radiation and surgery, D’Souza says. In recent years, surgeons have switched to complex, but minimally invasive, robotic surgery, which is D’Souza’s focus of research.

They are able to perform an esophagectomy through a keyhole incision using a surgical robot called a DaVinci Robot, which results in less trauma and less pain for the patients.

Studies have suggested that diet plays an important role in prevention. A healthier lifestyle prevents obesity and improves even the microbes in the tumor microenvironment, Jin says. She recommends eating more vegetables, more omega-3 rich fatty acids and less red meat, as well as cutting down on alcohol and smoking. CS