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Contributing Author, Cardiothoracic Surgeon

Cancer is a pervasive part of our society. It affects all ages and each generation has its unique experiences with this menace to our well being. Gastroesophageal cancer is a silent stalker here in the South.

More specifically, it is a cancer that develops at the junction between the esophagus, the tube that connects the stomachwith the mouth, greater part of their lives and its onset is slow and insidious. Recent statistics and my and the stomach itself. It often preys on patients who use alcohol and tobacco for the own personal experience suggest that this disease may be becoming more ominous and more aggressive that historical controls would indicate.

A typical patient with cancer of the esophagus seeks medical attention because of symptoms of dysphagia or difficulty swallowing and weight loss. The patient maybe unable to swallow solid food but may do OK with liquids. Other patients may find the reverse to be true. Usually the patient feels that he or she is otherwise healthy and has no unusual risk factors or recent illnesses. The duration of symptoms is usually 1 to 6 months and most patients have no history of this type of problem in their family. All are convinced that a pill from their doctor will fix whatever is wrong with them and they will be free to resume their usual activities and bad habits quickly. What are the real facts?

It is well accepted by cancer researchers that cancer of the distal esophagus and proximal stomach (GE junction tumors) are the end result of a multistage process involving an "initiation stage" and a "promotion phase." The initiation phase begins when a carcinogen (an alkylating agent or chemical irritant) attacks the wall of the esophagus or stomach. This initial damaged area may heal on its own, or if not properly repaired, lead to changes in the underlying cell structure.

The promotion phase occurs as the injured cell structure begins to grow faster than the cells surrounding the damaged area. This early lesion is called an in situ tumor or early tumor localized to a very superficial area of tissue. The following sequence of events seems to follow: Normal tissue leads to hyperplasia or fast growth cell structure and this leads to dysplasia or abnormal cell structure. The next step is in situ or early invasive cancer followed by full blown invasive cancer and then lastly metastasis or spread to other parts of the body. Most cancers in this area historically grow from either the lining of the esophagus (squamous cell) or the lining of the stomach (adenocarcinoma). We are also beginning to see unusual variants of other cell lines all with similar clinical presentations.

Most patients with cancer of the GE junction are in their 60ties. They are usually male and usually have enjoyed tobacco and alcohol for many years. A recent review at Memorial Hospital in New York of 258 patients showed a 27 month overall survival for adenocarcinoma arising from the stomach and a 22 month survival for tumors arising in the esophagus both treated with surgery. Patients treated with radiation or chemotherapy died in 7 months. More malignant types of tumor in this same area called small cell tumors often cause death in 6 months regardless of the type of treatment. If tumors can be discovered in their early phases, the survival rate for all tumor types is much higher with possibility for cures.

On the basis of my experience and published data, if the patient has early signs and symptoms related to swallowing and weight loss problems, the following tests are needed to rule out an early cancer.

1. chest x-ray
   
2. A CAT scan of the chest and abdomen
   
3. An endoscopy in which the surgeon looks down the esophagus with a scope at the area in question and performs a biopsy.
   
4. A barium swallow in which the radiologist asks you to swallow barium dye and then takes a series of x-rays to look at the area.
   
5. A bronchoscopy which is a test to look at the inside of the airways in the lung with a scope for any evidence of tumor extension into the lung.
   
6. An evaluation of the strength of your heart function and breathing capacity.
   
7. A bone scan to see if the tumor has spread to your bones.
   

Assuming that you pass all of the screening tests, then you may be a candidate for surgery and may have an increased hope for cure. Surgery itself is planned to remove all of the known tumor and then to reconnect the lower normal part of the stomach to the mid to upper portion of the remaining esophagus. The surgery sounds ghastly, but actually has worked well, and most patients are able to eat a normal diet and return to their usual activities.

Recommendations

1. Evaluate all early symptoms of weight loss and difficulty swallowing as soon as you can see your doctor.
   
2. The preoperative work-up outlined above can be used as a reference for the tests that you may need during this process.
   
3. There is hope for the future with early recognition of the problem and aggressive work-up. Your doctor may ask you to see an Oncologist for recommendations and perhaps a Radiation therapist. If you are a candidate for surgery this remains the gold standard for the best hope for cure. Good luck.