Frequent indigestion and choking on food? It could be oesophageal cancer

Oesophageal cancer is the ninth most common cancer and sixth most common cause of death worldwide.

It is endemic in third world countries. Incidence rates vary, with the highest rates found in southern and eastern Africa and eastern Asia, for both men and women.

Oesophageal cancer has always been associated with an unfavourable prognosis for survival.

The survival rate for five years varies from 4% to 40%.

As in most cancers, the key to a better prognosis is early detection.

Early diagnosis and treatment have always been a difficult task for both doctors and patients here in Malaysia.

One of the main reasons is poor awareness of this disease. Various forms of treatment are available in these modern times to achieve a cure, if the disease is detected early.

A 'defect' in the tube

The oesophagus is a long, hollow and muscular tube that runs from your throat to your stomach.

Basically, the oesophagus helps move the food you swallow from the back of your throat to your stomach to be digested.

To keep food and liquids moving in the right direction, this tube has rings of muscles along its course called sphincters.

Sphincters act like one-way valves. They relax to let food and liquid pass into your stomach and then tighten to prevent backflow, called reflux.

Glands in the lining of the oesophagus produce mucus, which keeps the passageway moist and makes swallowing easier.

When your oesophagus is working correctly, you may not even be aware of it. But when you try to swallow something too big, too hot, or too cold, you can definitely feel your oesophagus.

Oesophageal cancer can occur anywhere along this long tube, though it usually begins in the cells that line the inside of the oesophagus.

Oesophageal cancer occurs when cells in the oesophagus develop changes (mutations) in their DNA. The changes make cells grow and divide out of control.

A simple method of detection for higher risk patients would be to have an endoscopy done, in which a camera is inserted into the oesophagus to view the lining. — 123rf.com

The accumulating abnormal cells form a tumor in the oesophagus that can grow to invade nearby structures and spread to other parts of the body.

Early symptoms of this disease mimic the common symptoms, which a majority of us have, and these include stomach bloating, discomfort, heartburn, belching excessively and early satiety.

Late symptoms, when most patients come to the doctor, include difficulty in swallowing, choking on food, vomiting blood, unintentional weight and appetite loss.

A great number amongst our population feel their frequent symptoms will go away with time and never seek consultation. They commonly attribute this to their eating patterns or type of food taken.

Different types of cells

The two most common type of oesophageal cancer are the squamous type and the adenocarcinoma. The distinction betweenthe two lies in the type of cell.

In most Asian countries, including Malaysia, the squamous type is common. But this is slowly changing with modernisation and higher living standards.

Western countries have seen a dramatic rise in adenocarcinoma of the oesophagus.

One of the main causes of squamous cell carcinoma is tobacco chewing and alcohol consumption.

Smoking is also another main causes for oesophageal cancer.

In the western world, obesity and reflux disease are the causes for adenocarcinoma.

In Malaysia, we are beginning to see more of adenocarcinoma now compared to a decade ago.

The reason for this is the type of diet we consume at present.

Obesity has become a big problem in Malaysia. Fast foods, which are high in saturated fat, are easily available and is one the major contributing factors of weight gain.

Low intake of fruits and vegetables and high consumption of red meat have also been shown to contribute to this weighty problem.

A common symptom most of us would have experienced at some point or another is heartburn or better known as gastroesophageal reflux disease (GERD).

Constant heartburn can lead to a condition known as Barrett’s oesophagus, in which the lining of the oesophagus changes from normal to abnormal.

This condition maybe a precursor or one step away from oesophageal cancer.

Nabbing it early

The best cure for this disease is early detection.

Does this mean a doctor should see everyone with early symptoms? Of course not, as this will definitely overload our already stressed healthcare system.

Malaysia is a country with low to intermediate risk for oesophageal cancer. We are not able to screen all patients as in other diseases with high incidence rates such as colorectal cancer.

Targeted screening is a good and effective way to at least identify high-risk patients among us.

A local 2014 study,"Mark's Quadrant Scoring System: A Symptom-Based Targeted Screening Tool for Gastric Cancer", undertaken by Dr Mahadevan Deva Tata and a few of us, which was published in the Annals of Gastroenterology, showed that targeted screening of patients with symptoms is able to identify these high-risk patients.

A simple method of detection for these higher risk patients would be to be have an endoscopy done, in which a camera is introduced into the oesophagus to view the lining. A biopsy is taken if suspicious lesions are seen.

Patients with frequent symptoms of heartburn, stomach discomfort and swallowing difficulties should seek medical advice.

If symptoms persist despite medication by general practitioners, then it would be time to seek a specialist for an endoscopy.

A patient undergoes radiation therapy prior to having surgery, which is the option practised worldwide to treat advanced stages of cancer. — Filepic

Treatment for oesophageal cancer has evolved tremendously in the last decade. Newer forms of treatment have been used with excellent results.

For early oesophageal cancer detected on endoscopy, less invasive procedures are available. Endoscopic removal (removing of cancer via endoscopy) is widely practiced.

Expertise is available in Malaysia at various private and public hospitals.

With this method, small cancers can be removed just by using a specialised endoscope with added instruments, and patients will be able to go home in a day or two.

Once the cancer has been confirmed to have been totally removed, most patients would not need any further treatment.

These cancers mainly fall in the category of Stage 1 disease with no spread to other sites i.e. lymph nodes.

Advance treatment options

When a patient presents with cancer of Stage 2 or 3, this option may not be possible.

Other current forms of treatment are available but this may include surgery.

The best option currently practiced worldwide in many countries for disease with these stages is something known as preoperative (before surgery) chemo or chemoradiotherapy.

Patients who are fit to undergo this option are given courses of chemotherapy or a combination of chemotherapy and radiotherapy before surgery.

The reason for this is to actually shrink the tumour and possibly kill the microscopic or unseen cells of the cancer prior to surgery.

The benefits of this method include an easier removal of the tumour during surgery as it would be less bulky and enables a better clearance of the tumour.

Many studies have shown that this method has improved prognosis and survival of patients.

After the preoperative treatment, patients go through a rest period of three to eight weeks, before heading for surgery.

Modern techniques of surgery have evolved with good outcomes and less complications.

Minimally invasive surgery has been practiced for some time now in which surgery is done with tiny holes using laparoscopy.

This method does not involve large incisions. Recovery is much faster and with fewer complications.

More current techniques practiced in some countries include using robotic surgery as an option. Specialised expertise is needed to perform these procedures.

In Malaysia, robotic surgery is available in the fields of urology and gynaecology, but not yet in gastroenterology

Minimally invasive surgery is also practiced in other forms of malignant and benign disease.

It has proven to be beneficial to the patients in terms of faster recovery, less postoperative pain and quick return to work in some instances.

Once surgery is completed for oesophageal cancer, patients are then reassessed for suitability of further chemo or chemoradiotherapy.

This would depend on the final stage of the disease based on full biopsy after the surgery.

This completion therapy has shown to improve survival and prognosis as with preoperative treatment.

With this current treatment practiced worldwide with much evidence based on years of study, outcomes of oesophageal cancer has improved tremendously.

It is not a death sentence anymore, as it was perceived.

The most important single factor is early diagnosis and this can be achieved with education and public awareness of the nature of this disease.

Dr Ramesh Gurunathan is the president of the Malaysian Upper Gastrointestinal Surgical Society. For more information, e-mail [e-mail]. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.