Esophageal Cancer MATTHEW W. SHORT, LTC, MC, USA, Madigan Army Medical Center, Tacoma, Washington KRISTINA G. BURGERS, MAJ, MC, USA, Womack Army Medical Center, Fort Bragg, North Carolina VINCENT T. FRY, MAJ, MC, USA, Ireland Army Community Hospital, Fort Knox, Kentucky Esophageal cancer has a poor prognosis and high mortality rate, with an estimated 16,910 new cases and 15,910 deaths projected in 2016 in the United States. Squamous cell carcinoma and adenocarcinoma account for more than 95% of esophageal cancers. Squamous cell carcinoma is more common in nonindustrialized countries, and important risk factors include smoking, alcohol use, and achalasia. Adenocarcinoma is the predominant esophageal cancer in developed nations, and important risk factors include chronic gastroesophageal reflux disease, obesity, and smoking. Dysphagia alone or with unintentional weight loss is the most common presenting symptom, although esophageal cancer is often asymptomatic in early stages. Physicians should have a low threshold for evaluation with endoscopy if any symptoms are present. If cancer is confirmed, integrated positron emission tomography and computed tomog- raphy should be used for initial staging. If no distant metastases are found, endoscopic ultrasonography should be performed to determine tumor depth and evaluate for nodal involvement. Localized tumors can be treated with endoscopic mucosal resection, whereas regional tumors are treated with esophagectomy, neoadjuvant chemotherapy, chemoradiotherapy, or a combination of modalities. Nonresectable tumors or tumors with distant metastases are treated with palliative interventions. Specific prevention strategies have not been proven, and there are no recommen- dations for esophageal cancer screening. (Am Fam Physician. 2017;95(1):22-28. Copyright © 2017 American Academy of Family Physicians.) CME This clinical content sophageal cancer is the eighth cases worldwide.6 The highest rates occur conforms to AAFP criteria most common cancer worldwide. in China, Central Asia, and East and South for continuing medical Nearly four out of five cases occur Africa.2 The incidence of squamous cell car- education (CME). See CME Quiz Questions on page 8. in nonindustrialized nations, with cinoma in the United Sates is approximately Ethe highest rates in Asia and Africa.1,2 The three per 100,000 person-years.7 The inci- Author disclosure: No rel- evant financial affiliations. National Cancer Institute estimates that dence is consistent between sexes, is higher ▲ in 2016, there will be 16,910 new cases and among blacks, and peaks from 60 to 70 years Patient information: 8 A handout on this topic, 15,910 deaths from esophageal cancer in the of age. Important risk factors for esophageal 3 written by the authors of United States. squamous cell carcinoma include smoking, this article, is available Esophageal cancer is associated with a poor alcohol use, and achalasia9,10 (Table 18-15). at http://www.aafp.org/ prognosis. Despite advances in diagnosis and afp/2017/0101/p22-s1. Esophageal Adenocarcinoma html. treatment, the overall five-year survival rate for persons with esophageal cancer is 15% to Esophageal adenocarcinoma is the predomi- 20% worldwide and in the United States.4 nant type of esophageal cancer in North The two main subtypes of esophageal America and Europe6 (Figures 1 through 3). cancer are squamous cell carcinoma and According to 2013 data from the National adenocarcinoma. These subtypes account Cancer Institute, most cases occur in adults for more than 95% of malignant esophageal older than 50 years, and the incidence among tumors. Rare subtypes of esophageal can- persons 65 years and older is 11.8 to 16.3 cer, which are not discussed in this article, per 100,000 person-years, with an eightfold include lymphomas, melanomas, carcinoid higher risk in men compared with women tumors, and sarcomas.5 and a fivefold higher risk in whites compared with blacks3 (Table 18-15). Squamous Cell Carcinoma of the Major risk factors for esophageal adeno- Esophagus carcinoma include gastroesophageal reflux Squamous cell carcinoma is the most com- disease, obesity, and smoking.12-14 Barrett mon subtype of esophageal cancer outside esophagus is a known precursor disease to of the United States, accounting for 90% of esophageal adenocarcinoma with a low rate 22Downloaded American from Family the American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2017 American AcademyVolume of Family 95, Physicians. Number For 1 the◆ January private, noncom 1, 2017- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Esophageal Cancer WHAT IS NEW ON THIS TOPIC: ESOPHAGEAL CANCER In a cohort study of 11,028 patients with low- and high- grade dysplasia Barrett esophagus, the overall incidence of esophageal adenocarcinoma was 0.12% per year. Antireflux surgery appears to have minimal benefit in preventing esophageal cancer. A Cochrane review of 53 studies evaluating palliation for dysphagia showed that self-expanding metal stents are safe, effective, and provide quicker relief than brachytherapy, radiotherapy, esophageal bypass surgery, and chemotherapy. Table 1. Common Risk Factors for Esophageal Cancers Figure 1. Esophageal cancer at distal esophagus. Squamous cell carcinoma Adenocarcinoma (continued) Age 60 to 70 years White race (fivefold risk) Achalasia (10-fold risk) Gastroesophageal reflux Smoking (ninefold risk) disease (five- to sevenfold risk, depending Alcohol use (three- to on frequency of symptoms) fivefold risk with ≥ three drinks per day) Obesity (2.4-fold risk with body mass index Black race (threefold risk) > 30 kg per m2) High-starch diet without Smoking (twofold risk) fruits and vegetables Barrett esophagus Adenocarcinoma Age 50 to 60 years Male sex (eightfold risk) NOTE: Risk factors listed from most to least common. Information from references 8 through 15. Figure 2. Friable esophageal cancer at distal esophagus. of conversion. A cohort study of 11,028 patients with low- and high-grade dysplasia Barrett esophagus fol- lowed over a five-year period showed that the overall incidence of esophageal adenocarcinoma was 0.12% per year.16 A 41% reduced risk of esophageal adenocarcinoma has been observed among persons with Helicobacter pylori infection.17 It is believed that gastric acid secretions that contribute to reflux disease and Barrett esophagus are reduced as a result of gastric mucosa atrophy caused by H. pylori.18 This association is still under investiga- tion, and treatment of H. pylori infection continues to be recommended in accordance with American College of Gastroenterology guidelines. Clinical Presentation Figure 3. Extension of esophageal cancer as seen on retro- Esophageal cancer is often asymptomatic in the early flexed view from stomach. stages. Patients with advanced disease may present with progressive dysphagia (solids first, followed by liquids unresponsive to medication, chest pain, or signs of as the disease progresses), unintentional weight loss blood loss. (10% or more in the preceding three to six months), Of these symptoms, dysphagia alone or combined with odynophagia (painful swallowing, often noticed ini- unintentional weight loss is the most common presen- tially with dry foods), new-onset dyspepsia, heartburn tation in patients with esophageal cancer. Uncommon January 1, 2017 ◆ Volume 95, Number 1 www.aafp.org/afp American Family Physician 23 Esophageal Cancer findings include cervical adenopathy, hematemesis, LABORATORY TESTS hemoptysis, or hoarseness from recurrent nerve involve- After the diagnosis is confirmed with endoscopic biopsies, ment, which is present in less than 10% of patients at the additional laboratory studies may be helpful in evaluat- time of diagnosis.19 ing the tumor stage. The NCCN recommends evaluating Diagnosis The Society of Thoracic Surgeons and the Workup of Symptoms Suggestive of Esophageal National Comprehensive Cancer Network Cancer (NCCN) recommend that patients with the clinical presentation described previously Symptoms concerning for esophageal cancer undergo upper endoscopy as the initial diagnostic evaluation to exclude esophageal Upper endoscopy cancer 20,21 (Figure 4 20-23). Other indications warranting endoscopy include persistent upper abdominal symptoms despite medical therapy and upper abdominal symptoms in If suspicious lesion(s) present, Study results normal patients older than 45 years.24 perform biopsies or brushings Chromoendoscopy (topical application of Follow-up as stains to improve visualization of different necessary mucosal tissues) and narrow band imaging No evidence Adenocarcinoma or (use of blue and green light to improve visu- of malignancy squamous cell carcinoma alization of blood vessels and other mucosal features) are often used during endoscopy Follow-up as Integrated positron emission to improve identification of suspicious necessary tomography/computed lesions. Biopsies of suspicious lesions should tomography; laboratory tests be performed, but if esophageal stricture prevents adequate biopsies, brush cytology can also be used.25 Barium studies should be reserved for patients unable to undergo No distant metastases Distant metastases upper endoscopy.15 Endoscopic Evaluate for Staging ultrasonography palliative therapy Staging usually involves multiple modalities with brachytherapy or stenting in a stepwise approach and should be tai- lored to the patient as well