Treatment for oesophageal cancer depends on the tumour's location, cell type and extent of spread, as well as the person's general health. Surgery may be part of this plan. In many cases, cancer-fighting medicines, either alone or combined with radiotherapy directed at the tumour, are considered before surgery; for some patients, treatment without surgery is chosen.
New difficulty swallowing is one of the main reasons to investigate this disease, and particularly if food is getting stuck more often and weight is falling, it should not be dismissed as poor chewing or left to wait. Other causes are also possible. Investigations distinguish between them.
When should food getting stuck be investigated?
The oesophagus is the tube that carries swallowed food from the mouth to the stomach. When a tumour narrows its interior, solid foods such as meat and bread may become difficult to swallow first. A person may switch to softer food without realising it, try to wash each mouthful down with water and take longer to eat; as the problem progresses, swallowing liquids may also become difficult.
Pain when swallowing, unexplained weight loss, food coming back up, a persistent cough and hoarseness are also possible symptoms, but none of these is enough on its own to make a diagnosis. New difficulty swallowing in someone with long-standing heartburn needs a separate assessment; increasing the dose of an existing medicine does not establish the cause.
Being unable to swallow saliva or liquids, food becoming completely stuck, choking and breathlessness require emergency medical care. Vomiting blood and loss of consciousness are also symptoms that should not be left to wait. If drinking less is followed by reduced urination and severe weakness, possible dehydration needs to be assessed that same day.
At your appointment, you will be asked when the symptoms began, which foods make them worse and how your weight has changed. A list of your medicines and previous test results is helpful. Weight loss gives information not only about the tumour but also about how urgently nutritional support is needed.
Which tests are needed between diagnosis and treatment planning?
The main investigation is endoscopy: a thin, flexible camera is passed through the mouth into the oesophagus to examine its inner surface. Taking a small tissue sample from a suspicious area is called a biopsy. The laboratory determines whether the sample contains cancer cells and what type they are. The tissue result is needed too.
Once cancer is confirmed, its stage, or how far it has spread, is investigated. Computed tomography, or CT, produces cross-sectional images of structures in the chest and abdomen. In some cases, PET/CT, which also shows cell activity, and endoscopic ultrasound, which examines the oesophageal wall at close range, are needed. Not every patient is given every test.
The results may be assessed jointly by the surgeon, the oncologist who plans drug treatment and the radiotherapy specialist. Even if the tumour can technically be removed, heart and lung function, mobility, other medical conditions and nutritional status are assessed to establish whether the person can tolerate surgery.
Chemotherapy is drug treatment directed against cancer cells. Radiotherapy uses high-energy radiation directed at the tumour area. Depending on the characteristics of the disease, one or both may be given before surgery. The aim is to improve control of the tumour; the chosen sequence depends on the biopsy and staging results.
Very early, superficial tumours may be suitable for local removal using an endoscope. When surgery is unsuitable, chemotherapy combined with radiotherapy may instead be chosen as the main treatment. In disease that has spread to distant organs, drug treatment to control the cancer and measures to improve swallowing take priority. In selected cases, a tube-shaped stent is inserted to keep the narrowed area open; its suitability is considered as part of the overall plan.
What changes during an Ivor Lewis operation?
Oesophagectomy is the removal of part or most of the oesophagus. The Ivor Lewis approach has abdominal and chest stages. The section containing the tumour and the associated lymph nodes are removed. Lymph nodes are tissues belonging to the immune system, and the laboratory checks whether cancer has spread to them.
To restore the route for food, the stomach is usually shaped into a tube, brought up into the chest and joined to the remaining oesophagus. The new join is called an anastomosis. Because the tumour's location and previous procedures affect the choice of operation, the Ivor Lewis approach may suit one patient while another needs a different approach.
With the minimally invasive approach, the abdominal stage is performed laparoscopically and the chest stage thoracoscopically. Both terms mean that a camera and instruments are inserted through small incisions. This does not reduce the extent of the surgery inside the body. Risks such as leakage from the join, lung infection, bleeding and blood clots in the blood vessels remain.
The stages of the operation can be seen in the Ivor Lewis oesophagectomy video; it contains surgical footage intended for adults. Further information about the treatment approach is available on the minimally invasive surgery for oesophageal cancer page.
Eating and daily life after surgery
Recovery can take months. In the early stages, breathing exercises and gradually increasing movement go hand in hand with nutritional support, and feeding through a tube placed in the small intestine is sometimes needed until enough food can be taken by mouth. Having a tube does not mean that eating by mouth will never be possible again.
Because the stomach's shape and position have changed, smaller portions are easier to manage, while chewing food thoroughly, spreading fluid intake throughout the day and monitoring weight form part of a plan developed with a dietitian, a specialist in nutrition. A poor appetite does not mean the body needs less nourishment. If weight is falling, the plan is adjusted.
The return of stomach contents into the oesophagus is called reflux and can cause discomfort, particularly when lying down. Avoiding food shortly before bedtime, raising the head of the bed and taking medicines prescribed by your doctor may help. Sweating after meals can also occur. When food passes rapidly into the intestine, sweating may be accompanied by palpitations and diarrhoea; these symptoms should also be reported to the dietitian.
If narrowing develops at the join during healing, food may get stuck again and endoscopic dilatation may be needed. Increasing difficulty swallowing should not be left until a follow-up appointment. Fever, new chest pain, sudden breathlessness or an inability to swallow liquids after surgery requires urgent assessment.