Tell someone not to swallow, and it may as well be an instruction not to sleep, blink or breathe. For those facing esophageal cancer, though, trouble swallowing and eating is just the beginning.
The cancer is notoriously difficult to cure. But those facing esophageal cancer may soon get some help from a combination of powerful technologies. City of Hope researchers recently showed that uniting the advanced radiation system called TomoTherapy together with robotic surgery and potent chemotherapy may improve survival.
“Our initial results are encouraging,” said Yi-Jen Chen, M.D., clinical assistant professor of radiation oncology and a study author. “We plan to continue this treatment approach and refine it to benefit our patients, and perhaps influence care at other centers.”
The research team studied 20 patients treated at City of Hope from 2005 to 2007 for locally advanced esophageal cancer — cancer that's spread to nearby tissue or lymph nodes. Most patients like these would likely die of cancer within a year without any treatment, physicians said. With treatment, though, outcomes were much different.
Special radiation treatments
All of the patients received chemotherapy and radiation therapy; some also were able to undergo surgery after radiation.
Radiation oncologists used City of Hope's TomoTherapy Hi-Art System. Through TomoTherapy, radiation oncologists not only can administer therapy, but they also can create images through computed tomography to make sure they're precisely targeting a tumor and avoiding healthy tissue as much as possible.
That means physicians can administer radiation doses more evenly within esophagus tumors, while also sparing the nearby vulnerable structures of the neck, chest and upper abdomen.
High-tech surgical robots
After chemotherapy and radiation, 10 of the 20 patients were able to undergo surgery through City of Hope’s robotic methods, which involve removing the esophagus and potentially cancer-harboring lymph nodes nearby. The rest of the patients didn't undergo surgery, either because they chose not to or because surgery was deemed too risky for them.
A year later, all 10 patients treated through chemotherapy, radiation and surgery remained alive, compared to 58 percent of patients treated with chemotherapy and radiation. After two years, about 83 percent of the patients treated with chemotherapy, radiation and surgery remained alive.
“We’re excited to be able to bring our disciplines together to find solutions for this form of cancer,” said Kemp Kernstine, M.D., Ph.D., director of the Lung Cancer and Thoracic Oncology Program and one of the study’s co-authors.
A cancer on the rise
Improvements in care are desperately needed, as one particular form of esophagus cancer — adenocarcinoma — is growing more common. It's usually diagnosed at a late stage, making successful treatment tough.
“Adenocarcinoma is certainly on the rise, related to increased incidence of Barrett’s esophagus in the Western world,” explained Dean Lim, M.D., City of Hope medical oncologist and study co-author. In Barrett’s esophagus, the esophagus changes so that some of its lining becomes like tissue normally found in the intestine.
Barrett’s esophagus usually causes no symptoms itself, but it can sometimes lead to esophageal cancer. It's associated with the common condition called gastroesophageal reflux disease, or GERD. The risk of adenocarcinoma is 30 to 125 times higher in people who have Barrett's esophagus than it is in others, according to the National Institute of Diabetes and Digestive and Kidney Disorders.
“This is especially being seen with the increasing incidence of GERD, which is seen mostly in obese males,” Lim said.
About 15,560 people were diagnosed with esophageal cancer in 2007, according to the American Cancer Society. The disease is three to four times as common among men than among women.
IIn the West, the rate of adenocarcinoma of the esophagus in white men has been increasing at about 2 percent a year. Adenocarcinoma makes up most of the cases of esophageal cancer among white men, while squamous cell carcinoma is the most common form among African-American men.
Hard to swallow
Esophageal cancer causes few symptoms before the cancer is advanced, physicians say. Those at high risk for the cancer may benefit from screenings, though. Anyone with risk factors, including Barrett’s esophagus, should talk to their doctor about whether to get regular tests such as endoscopy with tissue biopsy.
Esophageal cancer may cause these symptoms:
difficulty swallowing, the most common symptom
pressure in the chest
unexplained weight loss
hoarseness, hiccups, pneumonia and high levels of calcium in the blood
These are a few of the risk factors associated with esophageal cancer:
Gastroesophageal reflux disease
Heavy use of alcohol
Diets low in fruits and vegetables, and diets low in vitamin A and C and riboflavin
Age (nearly half of those with the disease are over 70)
Source: American Cancer Society