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OESOPHAGEAL CANCER
( By JASCAP )

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Treating Oesophageal cancer

Treatment for oesophageal cancer

Treatment types

Cancer of the oesophagus can be treated using surgery,chemotherapy or radiotherapy. The choice of treatment will depend upon the exact type of oesophageal cancer, its stage, position and size, as well as your age and general health. The treatments can be used alone or in combination. When diagnosing and treating cancer doctors consider the oesophagus in three sections: upper, middle and lower.

Other treatments may be used to ease any swallowing difficulties you may have. These include: intubation or stenting (inserting a tube into the oesophagus to keep it open), dilatation (stretching the oesophagus), laser treatment and photodynamic therapy. You may be offered one or more of these treatments, which are described in greater detail on the difficulty in swallowing section.

Treatment planning

In most hospitals a team of specialists will discuss with you the treatment that they feel is best for your situation. This multidisciplinary team (MDT) will include a surgeon who specialises in oesophageal cancers, a medical oncologist (chemotherapy specialist), a clinical oncologist (radiotherapy specialist and chemotherapy specialist) and may include a number of other healthcare professionals such as a:

  • nurse specialist
  • dietitian
  • physiotherapist
  • occupational therapist
  • psychologist or counsellor.

Treatment choices

If two treatments are equally effective for your type and stage of cancer, your doctors may offer you a choice of treatments. Sometimes people find it very hard to make a decision. If you are asked to make a choice, make sure that you have enough information about the different treatment options, what is involved and the side effects you might have, so that you can decide which is the right treatment for you.

Talking about treatment

Remember to ask questions about any aspects that you don‟t understand or feel worried about. You may find it helpful to discuss the benefits and disadvantages of each option with your cancer specialist, nurse specialist or with our cancer support specialists.

If you have any questions about your treatment, don't be afraid to ask your doctor or nurse. It often helps to make a list of questions and to take a close friend or relative with you.

Giving your consent

Before you have any treatment your doctor will explain the aims of the treatment to you and you will usually be asked to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:

  • the type and extent of the treatment you are advised to have
  • the advantages and disadvantages of the treatment
  • any other treatments that may be available
  • any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need their treatment to be explained more than once.

It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go for your appointment.

People often feel that the hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you and the staff should be willing to make time for you to ask questions.

If you feel unable to make a decision about the treatment when it is first explained to you, you can always ask for more time. You are also free to choose not to have the treatment, and the staff can explain what may happen if you do not have it.

Benefits and disadvantages of treatment

Many people are frightened at the thought of having cancer treatments, particularly because of the potential side effects that can occur.

Although many of the treatments can cause side effects, knowledge about how treatments affect people and improved ways of reducing or avoiding many of these problems have made most of the treatments easier to cope with.

Treatment can be given for different reasons and the potential benefits will vary depending upon the individual situation.

Early-stage oesophageal cancer

In people with early-stage cancer of the oesophagus, treatment may be given with the aim of curing the cancer. Occasionally additional treatments are given to reduce the risk of it coming back.

Advanced-stage oesophageal cancer

If the cancer is at a more advanced stage, treatment may only be able to control it, leading to an improvement in symptoms and a better quality of life. Unfortunately, for some people the treatment will have little effect upon the cancer and they will get the side effects without many of the benefits.

Treatment decisions

If you have been offered treatment that aims to cure your cancer, deciding whether or not to accept the treatment may be simple. However, if a cure is not possible and the treatment is being given to control the cancer for a period of time, it may be more difficult to decide whether or not to go ahead.

Making decisions about treatment in these circumstances is always difficult, and you may need to discuss in detail with your doctor whether or not you wish to have treatment. If you choose not to, you can still be given supportive (palliative) care, with medicines to help control any symptoms.

Second opinion

A number of cancer specialists work together as a team to decide the most suitable treatment for each person. Even so, you may want to have another medical opinion. Most doctors will be pleased to refer you to another specialist for a second opinion, if you feel that this will be helpful. The second opinion may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will provide useful information.

If you go for a second opinion, it may be a good idea to take a friend or relative with you, and to have a list of questions ready, so that all your concerns are covered during the discussion.

Surgery for oesophageal cancer

Your doctor will discuss with you the most appropriate type of surgery. This will depend on the size and position of the tumour, and whether or not it has spread. It is important to discuss any operation fully with your doctor before it happens. You may find it helpful to make a list of any questions you have ahead of the discussion.

Remember, no operation or procedure will be done without your consent. Some types of surgery may mean that you need to stay in hospital for a few weeks.

The operation

The most common type of operation is where the section of the oesophagus containing the tumour is removed and the remaining length of oesophagus is re-attached to the stomach.

There are two main ways of doing this:

  • Trans-thoracic oesophagectomy cuts are made in the abdomen and the chest so that the affected part of the oesophagus can be removed.
  • Trans-hiatal oesophagectomy cuts are made in the abdomen and neck to remove the affected part of the oesophagus.

During these operations the top part of the stomach is often also removed. You will still be able to eat in the same way as before, but as the stomach will be higher than before (above the sheet of muscle which divides the chest from the abdomen instead of below) you will need to have smaller meals, more often. You may also find that you feel sick if you eat too quickly.

If it is not possible to join your stomach to the remaining part of the oesophagus, it may be possible to remove a section of your large bowel (colon) to replace the part of the oesophagus that has been removed. If your doctor suggests this type of surgery, they will explain in more detail what is involved.

During your operation the surgeon will check the area around the oesophagus. They will also remove some of the lymph nodes. This is called lymphadenectomy and is done because the nodes may contain cancer. The lymph nodes will be examined under a microscope.

Removing them helps to reduce the risk of the cancer coming back as well as helping the doctors to know the stage of your cancer.

Occasionally, the surgeon discovers that the tumour cannot be removed, after a planned operation to remove the cancer has begun. This may be because the tumour has spread or gone through the wall of the oesophagus, or because many lymph nodes are affected. If this happens, the surgeon may insert a tube (stent) instead, to make eating and swallowing easier for you.

After your operation

Most people will be nursed in the intensive care or high-dependency unit for a day or two. This is purely routine and does not mean your operation has gone badly or that there are complications. A machine called a ventilator may be used to help you to breathe again, this is routine in some hospitals.

Pain

It is likely that you will have some pain and discomfort after the operation. You will be given regular painkillers, but should let your nurse or doctor know if you are still in pain. You may have your pain controlled using an epidural. This is a fine plastic tube that is inserted into the space around your spinal cord so that a drug can be given to numb the nerves. Your doctor or nurse will explain this procedure to you.

Drips and drains

A drip will be used to give you fluids until you are able to eat and drink again. You may also have a naso-gastric (NG) tube. This is a fine tube that passes down your nose into your stomach or small intestine and allows any fluids to be removed so that you don't feel sick. This helps the area of the operation to recover. You will have chest drains in place for a few days. These are tubes that are inserted into your chest during the operation to drain away any fluid that may have collected around the lungs. The fluid drains into a bottle beside your bed. The chest drains can be uncomfortable; if they are, let your doctor or nurse know.

A physiotherapist will help you to clear your lungs of any fluid that may have built up as a result of your operation.

After your operation, you will be encouraged to start moving around as soon as possible. This is an essential part of your recovery. Even if you have to stay in bed, it is important to do regular leg movements to prevent blood clots forming in your legs, and deep breathing exercises to help keep your lungs clear. A physiotherapist and the ward nurses will help you with this.

Eating and drinking

At first you will not be able to drink fluids, and will only be allowed sips of liquid, until your doctor is satisfied that the join in the oesophagus is healing. It will be a few days before you are able to drink. Some surgeons will put a small feeding tube directly into the small bowel during surgery so that you can be fed through this while you are not able to eat or drink. The tube is put into the middle part of the small bowel (the jejunum) through a small cut made in the wall of the abdomen (tummy). It is usually removed after you have begun to swallow again normally.

You may feel afraid to swallow for a short while and may have a bad taste in your mouth. Mouthwashes can help relieve the bad taste. Gradually, you will be able to eat and drink fairly normally again. It is likely, however, that you will lose quite a lot of weight in the first few weeks after your operation. Try not to worry about it the weight loss is normal and should slow down once you begin eating well again. The weight loss does not mean that your cancer has come back few people return to the weight they were before the operation.

You may also have some diarrhoea for a while after the operation, which can usually be controlled with medicine if it continues.

We have booklets on nutritional support and dietary problems after surgery.

At home

Before you leave hospital you will be given an appointment to attend an outpatient clinic for your post-operative check up. This will be a good time to discuss any problems you have after your operation. But remember, you can usually ring your hospital doctor, specialist nurse or ward nurse any time if you have problems.

Radiotherapy for oesophageal cancer

Radiotherapy treats cancer by using high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal cells. Radiotherapy is directed at specific parts of the body and may be given externally or internally.

External radiotherapy

External radiotherapy may be given before or after surgery. Depending upon the circumstances, it may also be given at the same time as chemotherapy.

The treatment is given in the hospital radiotherapy department as short daily sessions from Monday to Friday, with a rest at the weekend. The length of your course of radiotherapy treatment will depend on the type and size of the cancer. Your doctor will discuss the treatment with you.

Planning your treatment

Planning is a very important part of radiotherapy and makes sure that it is as effective as possible. On your first visit to the radiotherapy department you will be asked to have a CT scan or lie under a machine called a simulator, which takes x-rays of the area to be treated. The treatment is planned by a cancer specialist (clinical oncologist) and may take a few visits.

The radiographer (the person who gives you your treatment) will make small marks on your skin, to show where the rays are to be directed. During the course of treatment this area should be kept as dry as possible to prevent the skin becoming red and sore. Your radiographer will explain how to look after the area being treated.

Treatment sessions

Before each session of radiotherapy, the radiographer will position you carefully on the couch and make sure that you are comfortable. The treatment only takes a few minutes. You will be left alone in the room but will be able to talk to the radiographer, who will be watching you from the next room.

Radiotherapy is not painful, but you do have to lie still for a few minutes while your treatment is being given. The treatment will not make you radioactive, and it is perfectly safe for you to be with other people, including children, after your treatment.

Side effects of external radiotherapy

Radiotherapy can cause general side effects such as feeling sick (nausea) and tiredness, but is also likely to make the inside of your gullet inflamed, causing short-term soreness when you swallow. It is not unusual to feel worse before things start to feel better.

Some people can find this a very difficult time and they may feel rather depressed for a while. These side effects can be mild or more troublesome, depending on the strength of the radiotherapy dose and the length of your treatment. The clinical oncologist will be able to advise you on what to expect.

Sore throat and difficulty swallowing

The radiotherapy may make your throat very sore towards the end of the treatment, and you may not be able to swallow properly for a while. Medicines are available that may help to relieve the discomfort caused by the sore throat. You may be advised to have a feeding tube put into your stomach (known as a PEG tube) before the radiotherapy starts. Your doctor can advise you whether or not this will be necessary.

PEG stands for percutaneous endoscopic gastrostomy and is carried out under local anaesthetic. A flexible tube with a light at the end (endoscope) is passed down the throat and oesophagus into the stomach, to find a suitable area to insert the tube. A cut is then made in the skin and muscle over the stomach and a tube passed through a cut made in the stomach itself. The tube is usually held in place with a rubber or silicon disk (flange). Liquid feeds can be given through the tube.

Our booklet on nutritional support discusses PEG tubes and feeding in detail.

Dry mouth

If the radiotherapy is given to the upper end of the oesophagus, it may reduce the amount of saliva your salivary glands produce. This effect may be temporary, but occasionally can be permanent. This may make your mouth dry, which can make eating difficult.

Feeling sick reduced appetite

Feeling sick (nausea) can usually be treated by anti-sickness drugs (anti-emetics), which your doctor can prescribe. If you don't feel like eating, you can replace meals with nutritious, high-calorie drinks, which you can get from most chemists. Our booklet on diet and cancer has some helpful hints on how to eat well. You can discuss any problems with your doctor.

Hair loss

When radiotherapy is used to treat the oesophagus, men may find that some of the hair on their chest may fall out.

Tiredness

As radiotherapy can make you tired, you should try to get as much rest as you can, especially if you have to travel a long way for treatment each day.

All these side effects should disappear gradually once your course of treatment is over, but it is important to let your doctor know if they continue.

Internal radiotherapy (brachytherapy)

This is given by inserting a radioactive metal rod, known as a source, into the oesophagus. It is left there for between 30 minutes and a couple of days, depending on the amount of radiation that is needed. In this way more focused treatment is given to the inside of the oesophagus in a short time, rather than a course of external radiation given to a wider area over a longer time.

There are two ways of giving this type of treatment:

  • through an endoscope
  • through a nasogastric (NG) tube.

Endoscope

Your doctor will put the radioactive source in the oesophagus using an endoscope similar to the one used to diagnose oesophageal cancer. You will be given a sedative to make you feel sleepy so that the endoscope can be easily passed into your oesophagus. The radioactive source is contained within a tube that is placed next to the cancer. The endoscope is then removed. When the treatment is finished the doctor uses the endoscope to remove the tube containing the radioactive source.

Nasogastric tube

A nasogastric tube (or NG tube) is a thin flexible, plastic tube that goes up your nose, down the back of your throat and into your stomach. Having a nasogastric tube put in can be unpleasant but should not be painful. The NG tube contains the radioactive source, which can be placed close to the cancer. When the period of treatment is over, the NG tube is removed.

Once the radioactive source has been removed, there is no remaining radiation within your body.

Side effects of internal radiotherapy

As with external radiotherapy, internal radiotherapy causes temporary soreness when you swallow, which may develop a few days after treatment and last for a few days. Your doctor will recommend liquid medicines to help you swallow and to soothe the soreness. Unlike external radiotherapy, this treatment does not cause tiredness or nausea and there is no hair loss.

If you have to stay in hospital for a few days while the radioactive source is in place, your family or close friends will only be able to visit you for short periods each day. It is not advisable to allow children or pregnant women to visit while you are having this type of radiotherapy. These precautions can make you feel isolated, but they only last for the few days that the radioactive source is in place. Once it has been removed the radioactivity disappears.

Chemotherapy for oesophageal cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. They work by disrupting the growth of the cells. Chemotherapy drugs that are commonly used to treat oesophageal cancer are fluorouracil (also known as 5FU), cisplatin and epirubicin. These drugs may be given together and are known as the ECF regimen.

A tablet form of 5FU called capecitabine (Xeloda®) is sometimes used in place of the intravenous (drip) 5FU. The combination is then known as the ECX regimen.

When it is given

If you are able to have surgery to remove your oesophageal cancer, chemotherapy is often given before the operation to help to reduce the chance of the cancer coming back. It may also be given if your doctors think that the tumour is too large to be removed by surgery, as the chemotherapy can sometimes shrink the cancer and make it easier to remove. Chemotherapy given before an operation is known as neo-adjuvant chemotherapy.

Chemotherapy may also be given after surgery if it was not possible to remove all of the tumour during the operation, or if there is a high risk that it may come back. Chemotherapy given after surgery is known as adjuvant therapy.

Chemotherapy is sometimes given alongside radiotherapy (known as chemoradiation). It is mainly used for squamous cell cancer (but can be used for adenocarcinoma too). Giving chemotherapy at the same time as radiotherapy may improve the effectiveness of radiotherapy. However, giving the two treatments at the same time also increases the side effects.

If the cancer has spread to other parts of the body, chemotherapy may be used as the main treatment. This aims to shrink the tumour, improving symptoms and extending good-quality life. In some people the chemotherapy will achieve this. Unfortunately, for other people the chemotherapy will not shrink the cancer and they will have the side effects of the treatment with little benefit.

It is helpful to discuss with your cancer specialist the benefits and side effects of chemotherapy in your particular situation. If you have a cancer that has spread, and you decide that you do not want to have chemotherapy, your doctor can still prescribe medicines that may help to control symptoms caused by the cancer.

How it is given

Before any chemotherapy is prescribed, you may need to have a test to check how well your kidneys are working (kidney function). This is because the dose of one of the chemotherapy drugs is decided according to your kidney function. This may involve just a blood test or you may be asked to collect all of your urine for 24 hours and to give a blood sample.

You may be asked to attend the hospital for an EDTA test, which is a specialised test that measures kidney function. An EDTA (ethylene diamine tetraacetic acid) test involves giving you an injection of a mildly radioactive liquid and taking two blood samples.

It is usual for chemotherapy treatment to consist of a combination of two or more drugs. These are often given by injection into a vein in your arm (intravenously). It may mean staying in hospital for a few days, or you may be able to be treated as a day patient. The treatment is generally repeated every three weeks, but in the three week interval while you are at home, one of the drugs fluorouracil or 5FU may be given continuously through a fine plastic tube (called a central line) put into a vein in your chest.

The central line is either stitched or taped firmly to your chest, and can be kept in the vein for many months. Sometimes, a tube may be put into a vein in the crook of your elbow instead of into the chest. This is known as a PICC line (peripherally inserted central catheter).

A small pump can be attached to the central line or PICC line to allow a continuous dose of one of the chemotherapy drugs to be given day and night, while you are at home. The pump can be carried round in a small bag, that is worn around the waist or over the shoulder.

Most of the chemotherapy drugs for oesophageal cancer are given by injection into a vein in your arm (intravenously) or through a central line or PICC line. Research is now in progress using a tablet called capecitabine (also known as Xeloda®), instead of giving fluorouracil through the central line.

Side effects

Chemotherapy drugs may cause unpleasant side effects, but these can usually be well controlled with medicines. Not all drugs cause the same side effects and some people may have very few side effects. Your doctor will tell you about any problems that your treatment may cause.

Lowered resistance to infection

While the drugs are acting on the cancer cells in your body, they also temporarily reduce the number of normal white cells in your blood. When these cells are reduced, you are more likely to get an infection and you may tire easily. Your blood will be tested regularly during chemotherapy and, if necessary, you may be given antibiotics to treat any infection.

If your temperature goes above 38C (100.5F), or you suddenly feel unwell, even with a normal temperature, you may have an infection. Contact your chemotherapy nurse or doctor at the hospital straight away.

Anaemia

If the level of red blood cells (haemoglobin) in your blood is low you will probably feel very tired and lethargic. You may also become breathless. These are all symptoms of anaemia a lack of haemoglobin in the blood.

Anaemia can be very successfully treated by blood transfusions. These should help you to feel more energetic and ease the breathlessness.

Bruising and bleeding

Platelets are a type of blood cell which help to clot the blood. If the number of platelets in your blood is low you will bruise very easily and may bleed heavily from even minor cuts or grazes. If you develop any unexplained bruising or bleeding, contact your doctor or the hospital immediately.

Our information on platelet transfusions explains this in more detail.

Feeling sick

Some of the drugs used to treat oesophageal cancer can make you feel, or be, sick (nausea and vomiting) , but there are very effective anti-sickness drugs (anti-emetics) to prevent this. It is helpful to avoid eating immediately before and after your chemotherapy. If the sickness is not controlled or continues, even with anti-sickness treatment, let your doctor know. They can prescribe other medicines that may be more effective.

Tiredness

Chemotherapy affects people in different ways. Some people find they are able to lead a fairly normal life during treatment, but many find they have to take things much more slowly. Tiredness can build up over a course of treatment, and if you have a lot of chemotherapy, it can last for several months or more after your treatment has finished. It is best to cope with tiredness by planning ahead. Try to fit in rest periods and don‟t do things that you don‟t need to do. Accept help from others when you need to. There may be times when you feel less tired. A little activity can sometimes help with the symptoms of fatigue.

Sore mouth and loss of appetite

Some chemotherapy drugs can make your mouth sore and cause small ulcers. It is important to rinse your mouth regularly to keep it clean. Using a child‟s soft toothbrush can be helpful. If you don't feel like eating during treatment, you could try replacing some meals with nutritious drinks or a soft diet.

Our booklet on eating well provides useful tips on coping with eating problems. Our information on mouth care during chemotherapy and diet in this section may be helpful.

Hair loss

Unfortunately, some chemotherapy drugs will make your hair fall out. If you lose your hair it will start to grow back within three to six months of finishing your treatment. People who lose their hair often cover up by wearing wigs, bandanas, hats or scarves. If you are being treated as an inpatient, or you are on income support, you can get a free wig from the NHS. If not, you can still get a subsidised wig from the hospital. Ask the team looking after you if a wig specialist is available to visit you. If your hair falls out it is important to protect your scalp from the sun.

Numbness or tingling in hands or feet

This is due to the effect of cisplatin on nerves and is known as peripheral neuropathy. Tell your doctor if you notice these symptoms. This problem usually improves slowly over a few months after the treatment is over

Diarrhoea

Some of the chemotherapy drugs used to treat oesophageal cancer can cause diarrhoea. This often starts several days after the chemotherapy. If you are taking chemotherapy tablets at home it is important to tell your doctor if you have diarrhoea more than 46 times a day, as your treatment may need to be stopped.

Your doctor can give you medicine to help slow down and stop the diarrhoea. It may help to follow a low-fibre diet if you can. It is important to drink plenty of fluids if you have diarrhoea.

Sore hands and feet

Soreness of the palms of the hands or soles of the feet can occur when 5FU or capecitabine are given over a long period of time, or when they are given continuously through a pump. It is known as palmar-plantar syndrome. A vitamin can be prescribed to help control this side effect and simple moisturising creams can often help to relieve symptoms.

Chemotherapy affects people in different ways. Some find they are able to lead a fairly normal life during their treatment, but many find they become very tired and have to take things much more slowly. Just do as much as you feel like and try not to overdo it.

Our booklet on chemotherapy discusses this treatment and its side effects in more detail.

Research - clinical trials for oesophageal cancer

Cancer research trials are carried out to try to find new and better treatments for cancer. Trials that are carried out on patients are known as clinical trials.

Clinical trials may be carried out to:

  • test new treatments, such as new chemotherapy drugs, gene therapy or cancer vaccines
  • look at new combinations of existing treatments, or change the way they are given, in order to make them more effective or to reduce side effects
  • compare the effectiveness of drugs used for symptom control
  • find out how cancer treatments work
  • see which treatments are the most cost-effective.

Trials are the only reliable way to find out if a different operation, type of chemotherapy, radiotherapy, or other treatment is better than what is already available.

Taking part in a trial

You may be asked to take part in a treatment research trial. There can be many benefits in doing this. Trials help to improve knowledge about cancer and develop new treatments. You will also be carefully monitored during and after the study. Usually, several hospitals around the country take part in these trials. It is important to bear in mind that some treatments that look promising at first are often later found not to be as good as existing treatments, or to have side effects that outweigh the benefits.

Blood and tumour samples

Many blood samples and bone marrow or tumour biopsies may be taken to find out what is wrong with you. You may be asked for your permission to use some of your samples for research into cancer. Some samples may be frozen and stored for future use, when new research techniques become available.

The research may be carried out at the hospital where you are treated, or it may take place at another hospital. This type of research takes a long time, so you are unlikely to hear the results. The samples will, however, be used to increase knowledge about the causes of cancer and its treatment. This research will, hopefully, improve the outlook for future patients.


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