Stomach and Oesophageal Cancers
- What are stomach and oesophageal cancers?
- What are the symptoms of stomach and oesophageal cancers?
- What are the risk factors?
- How are stomach and oesophageal cancers diagnosed?
- The staging and prognosis of stomach and oesophageal cancers
- Treatment for stomach cancer
- Treatment for oesophageal cancer
- Managing side effects of treatment for stomach and oesophageal cancers
- Life after treatment
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Stomach and Oesophageal Cancers
Treatment for oesophageal cancer
The most important factor in planning treatment for oesophageal cancer is the stage of the disease. Your treatment will also depend on your age, nutritional needs, medical history and general health.
The main treatments for oesophageal cancer are surgery, radiation therapy and chemotherapy, either alone or in combination. Treatment will be tailored to your specific situation.
Oesophageal cancer that has not spread outside the oesophageal wall can generally be treated with surgery. Your doctor will tell you how to prepare for surgery. For example, you may need to treat any nutritional issues before surgery or, if you are a smoker, stop smoking.
Surgery aims to remove all of the cancer while keeping as much normal tissue as possible. The surgeon will remove some healthy tissue around the cancer to reduce the risk of the cancer coming back. You may have an endoscopic resection or an oesophagectomy depending on where the tumour is growing and how advanced the cancer is.
Endoscopic resection (ER)
Very early-stage tumours that have not spread from the oesophageal wall may be removed with an endoscope. For some people, an endoscopic resection may be the only treatment needed. This is usually a day or overnight-stay procedure. Preparation and recovery are similar to endoscopy.
Oesophagectomy (surgical resection)
This procedure removes the cancerous tissue and part or all of the oesophagus, leaving as much healthy tissue as possible. The goal is to completely remove the cancer, including nearby affected lymph nodes. It is common to have chemotherapy and/or radiation therapy before an oesophagectomy, as this has been shown to lead to better outcomes.
Depending on where in the oesophagus the cancer is located, the surgeon may also remove a part of the upper stomach. This is the preferred option for tumours that have spread deeper into the wall of the oesophagus or to nearby lymph nodes.
Once the cancerous sections have been removed, the stomach is pulled up and reconnected to the healthy part of the oesophagus. This will allow you to swallow and, in time, eat relatively normally. Occasionally, if the oesophagus cannot be reconnected to the stomach, the oesophagus will be connected to the small bowel or a piece of large bowel will be used to help you swallow.
How the surgery is done
To remove the cancerous tissue, the surgeon will need to access the upper abdomen and chest. This may be done in two ways:
- in an open oesophagectomy, the surgeon will open the chest and the abdomen with large surgical cuts
- in a minimally invasive oesophagectomy (keyhole or laparoscopic surgery), the surgeon will make some small cuts in the abdomen and/or between the ribs, then insert tools into the cuts. One of the tools will have a light and camera so the surgeon can see inside the body.
The hospital stay and recovery time are fairly similar for both types of surgery. Although laparoscopic surgery usually means a smaller scar, open surgery may be considered a better option in many situations.
Risks of oesophageal surgery
As with any major surgery, oesophageal surgery has risks. These may include infection, bleeding, blood clots, damage to nearby organs, leaking from the connections between the oesophagus and stomach or small bowel, pneumonia and paralysis of the vocal cords. Some people may experience an irregular heartbeat, but this usually settles within a few days. Narrowing of the oesophagus from surgical scars (known as oesophageal stricture) can make it difficult to swallow. Your doctor may perform a procedure to stretch the walls of the oesophagus (dilatation). Some people need to have only one dilatation, others need many. Your surgeon will discuss these risks with you before surgery, and you will be carefully monitored for any side effects.
What to expect after oesophageal surgery
Recovery after oesophageal surgery is similar to the overview for stomach surgery, but there are some differences:
Recovery time – You will probably be in hospital for 7–10 days, but it can be significantly longer if any complications occur. It generally takes 6–12 months to recover from an oesophagectomy.
Drips and drains – You will have a tube down your nose into your stomach (nasogastric tube) to drain fluids from the stomach.
Dietary changes – As with stomach surgery, you will not be able to eat or drink straight after surgery. It is common for a temporary feeding tube to be inserted at the time of your surgery. You can be given specially prepared feeding formula through this tube while the join between the oesophagus and stomach heals. Once you begin eating, it is common to start with fluids such as soup, and then move onto soft foods for a few weeks. You may be advised to eat 5–6 small meals or snacks throughout the day.
Breathing problems – It is important that your pain is controlled to help avoid problems with breathing that can lead to pneumonia. To reduce the risk of pneumonia, a physiotherapist will teach you breathing or coughing exercises that help keep your lungs clear. You may also be taught how to use an incentive spirometer, a device you breathe into to help your lungs expand and prevent a chest infection.
Also known as radiotherapy, this treatment uses a controlled dose of radiation, such as focused x-ray beams, to kill or damage cancer cells. The radiation is targeted at the cancer and treatment is carefully planned to do as little harm as possible to healthy body tissue near the cancer.
Radiation therapy may be given alone or combined with chemotherapy (chemoradiation). It is commonly used before surgery to shrink large tumours and destroy any cancer cells that may have spread. In this case, there will be a break of one to two months between radiation therapy and surgery to allow the treatment to have its full effect. Radiation therapy, with or without chemotherapy, is also used as the main treatment for oesophageal cancer that has not spread to other parts of the body and cannot be removed surgically.
Before starting treatment, you will have a planning appointment that will include a CT scan. The radiation therapy team will use the images from the scan to plan your treatments. The technician may make some small permanent tattoos or temporary marks on your skin so that the same area is targeted during each treatment session.
You will usually have treatment as an outpatient once a day, Monday to Friday, for 4–5 weeks. If radiation therapy is used palliatively, you may have a short course of 1–10 sessions. Each treatment takes about 20 minutes and is not painful. You will lie on a table under a machine that delivers radiation to the affected parts of your body. Your doctor will advise you about your treatment schedule.
Side effects of radiation therapy
Many people will develop temporary side effects during or shortly after treatment. The lining of the oesophagus can become very sore and inflamed (oesophagitis). This can lead to painful swallowing and difficulty eating. In rare cases, you may need a feeding tube to ensure you receive enough nutrition. Other common side effects include fatigue, skin redness, loss of appetite and weight loss. Most side effects settle within four weeks of treatment finishing.
More rarely, some people will develop long-term side effects. Radiation therapy can cause scar tissue and narrowing of the oesophagus (known as oesophageal stricture). This can make it difficult to swallow, and your doctor may perform a procedure to stretch the walls of the oesophagus (dilatation). Radiation therapy can also create inflammation in the lungs, causing shortness of breath.
Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells, while causing the least possible damage to healthy cells. Chemotherapy for oesophageal cancer may be given alone or combined with radiation therapy.
For oesophageal cancer, chemotherapy is commonly given before surgery to shrink large tumours and destroy any cancer cells that may have spread. It may be used after surgery to reduce the chance of the disease coming back. Chemotherapy is also used on its own for people unable to have surgery.
Chemotherapy is usually given as a liquid through a drip inserted into a vein in the arm. It may also be given through a tube implanted into a vein (called a port, catheter or vascular access device), or as tablets you swallow. You will usually receive treatment as an outpatient.
Most people receive a combination of drugs in repeating rounds of treatment for several months. These may be given on one day, or continuously using a small pump that is linked to the implanted tube. There may be a rest period of a few weeks between each round. Your doctor will talk to you about how long your treatment will last.
Side effects of chemotherapy
The side effects of chemotherapy vary greatly, depending on the drugs you receive, how often you have treatment, and your general fitness and health. Most side effects are temporary. Your treatment team can help you prevent or manage any side effects.
Side effects may include nausea and/or vomiting, sore mouth or mouth ulcers, appetite changes and difficulty swallowing, skin and nail changes, numbness or tingling in the hands or feet, ringing in the ears or hearing loss, changed bowel habits (e.g. constipation, diarrhoea), and hair loss or thinning. You may also be more likely to catch infections. If you feel unwell or have a temperature higher than 38°C, seek urgent medical attention.
When radiation therapy is combined with chemotherapy, it is known as chemoradiation. The chemotherapy drugs make the cancer cells more sensitive to radiation therapy.
Oesophageal cancer may be treated with chemoradiation before surgery. Chemoradiation may also be used as the main treatment for oesophageal cancer when the tumour can’t be removed safely with surgery.
If you have chemoradiation, you will usually receive chemotherapy a few hours before some radiation therapy appointments. Your doctor will talk to you about the treatment schedule and how to manage any side effects.
Palliative treatment aims to help maintain a person’s quality of life by managing the symptoms of cancer without trying to cure the disease. It can help at any stage of advanced oesophageal cancer. Treatments will be tailored to your individual needs. For example, radiation therapy can help to relieve pain and make swallowing easier by helping to shrink a tumour blocking the oesophagus. Palliative treatments can also slow the spread of the cancer.
People with advanced oesophageal cancer who are having trouble swallowing and do not have any other treatment options may have a flexible tube (stent) inserted into the oesophagus. The stent expands the oesophagus to allow fluid and soft food to pass into the stomach more easily. This stent also prevents food and saliva going into the lungs and causing infection. The stent does not treat the cancer but will allow you to eat and drink more normally. Stents can cause indigestion (heartburn) and discomfort. Occasionally, the stents will move down the oesophagus into the stomach and may need to be removed.