When I Die: Lessons from the Death Zone

A Short Introduction to Oesophageal/Gastro-oesophageal Cancers

The oesophagus leads from the mouth into the stomach. The tumours that develop in the lower area of the oesophagus, called adenocarcinomas, are commonly grouped with cancers in the area of the gastro-oesophageal junction. Much of the treatment and research work in this field has dealt with these together. They are separate from the different cancers that affect the middle and upper parts of the oesophagus, which require a separate management approach.

In total, every year around half a million people worldwide are diagnosed with oesophageal cancer, and more than four hundred thousand of them die of the disease. It remains very difficult to treat, as frequently it will have spread from the primary tumour site by the time of diagnosis, preventing it from being surgically removed and so requiring any treatment to focus on simply control and containment.

Even when surgery is undertaken with curative intent, the majority of patients suffer recurrences and succumb to their disease. On the most recent data for gastro-oesphageal cancers, five-year survival following surgical resection and peri-operative chemotherapy or post-operative chemo-radiation ranges from 30 to 35 per cent.

And it is a disease that is on the rise. According to Cancer Research UK, there has been a marked increase in the incidence of adenocarcinoma of the lower third of the oesophagus and gastro-oesophageal junction in Britain over the past two to three decades. This is particularly true in Scotland, and most notably among men. The male to female ratio is now more than two to one, making it one of the highest gender differentials of any non-occupational cancer.

The risk of developing the disease also increases with age, with it by far most commonly occurring in the older population. Overall, oesophageal cancer is responsible for almost 3 per cent of all cancers in the United Kingdom and is therefore in the top ten of cancers in this country.

There is undoubtedly scope for improving outcomes, the main factor being earlier diagnosis, before the disease becomes too established in a patient. The problem with this is that the symptoms of early gastro-oesophageal cancer are very common, especially heartburn/indigestion/dyspepsia. It is now being stressed by clinicians that any new symptoms such as these are enough to warrant seeking medical advice. Diagnosis at an early stage should increase the chances of obtaining a cure. But this will also be aided by improving local treatments with enhanced surgical techniques and more modern radiotherapy equipment.

Where the disease recurs or has already spread at the time of diagnosis, there is development work in progress on better general treatments. Combination chemotherapy offers benefits with respect to tumour response and survival when compared to single agent chemotherapy regimens, but this comes at a cost of increased toxicity. The older age of many patients, the fact they are likely to have other common health issues, plus cancer-related debilitation frequently lead to difficulties in successfully applying this approach and it also makes it often problematic to enter these patients into clinical trials.

In order to improve these outcomes and avoid the toxicity of conventional cytotoxic chemotherapy, the focus of many investigators’ research has shifted to the use of novel molecular therapies. This involves identifying cell characteristics that will enable targeting treatment very specifically to each individual cancer.

A major example of this is Trastuzumab (herceptin) for patients with gastro-oesophageal cancer that on laboratory analysis is positive for the HER-2 receptor. And the work is going further, beyond cell level, to look at each patient’s genetic material. This is heading towards the goal of personalised medicine which will lead to the provision of individually targeted treatments.

This introduction to cancer of the oesophagus was contributed to this book by Dr Kaz Mochlinski and other staff at the Royal Marsden Hospital.