Gastroenterology - Oesophageal (Gullet) Cancer

Introduction

This information leaflet is intended to explain the management plan for your condition. It is not meant to frighten or discourage you. It is hoped that it will help you by explaining how we choose the most suitable treatment for you.

Your care will be managed by The Upper GI Multidisciplinary Team. The team includes:

• Surgeons
• Radiologist
• Pathologist
• Upper GI Specialist Nurse
• Palliative Care Nurse
• Dietitian
• MDT Coordinator

You will be allocated a Key Worker (usually the Specialist Nurse) who will be your point of contact to the team. You can contact your Key Worker if you have any questions or concerns about your diagnosis, investigations or treatment plan.

Diagnosis and treatment

You have been diagnosed as having cancer of the oesophagus. The oesophagus is sometimes known as the gullet. It is a long muscular tube, through which food travels from your mouth to your stomach after swallowing.

The food is passed down the oesophagus by muscular movements known as peristalsis.
 
There are a number of different ways of treating patients with this condition. Some treatments aim to cure the problem once and for all. In some patients the tumour is incurable even at the time of diagnosis. In this situation the treatments are palliative - this means trying to control the symptoms in as gentle a way as possible, whilst not being able to cure the tumour itself.

We are committed to commencing appropriate treatment as soon as possible. Often, however, some further important tests are needed to help determine what the best form of treatment should be.

These tests are called staging tests, and they help to find out whether or not the growth has spread. All tests are carried out for very good reasons, and we try to be as efficient as possible in organising them.

Oesophageal cancer staging tests

Usually, potentially curative treatments for oesophageal cancer involve a major operation, sometimes with extra chemotherapy or radiotherapy as well. These are not simple treatments and carry significant risks to patients. We only consider this treatment for patients who are fit enough to go through it safely, and in those in whom we think there is a good chance of cure.

To find out if a tumour might be curable the important questions to answer are:

Has the cancer grown right through the wall of the oesophagus?

Do the glands (lymph nodes) around the oesophagus have cancer cells in them?

Has the tumour already spread to involve other, distant organs in the body?

In order to answer these questions, you may need some or all of the following investigations for which you will be given specific information prior to these being performed:

1)    CT scan ('CAT' or body scan)

This is a good test to assess spread to distant organs such as liver or lung. This test is done in the x-ray department. The test is painless, completed quickly and does not require admission to hospital.

If the test shows distant organ spread, then the disease cannot realistically be cured with an operation. You will be advised to have palliative treatment. If the test is clear, then you will proceed to the next staging test.

2)    PET scan

Patients with potentially curable cancer need to have a PET scan. This is another body scan that shows how body tissues are working, as well as what they look like. The scan will show the tumour and will also highlight the areas of cancer spread, which is important information when planning treatment.

If you are diabetic it is important that your blood sugar is below 12 when you have your scan - it is important to contact the PET scanning department if you are experiencing uncontrolled blood sugar levels.

3)    Endoscopic ultrasound (EUS)

This is a good test to see whether the tumour has grown through the oesophageal wall, and to assess the nearby lymph glands. It helps to distinguish between early tumours, which may need just an operation, and more advanced tumours, which although technically removable, might need extra chemotherapy first. It can also show if the tumour is stuck to other important organs, which would make it impossible to remove safely.

The test is rather like an endoscopy (which you will already have had). It involves swallowing a specially modified scanning telescope. You will have sedation to make you sleepy for this test.

The procedure is done as a day case - you will not need to be admitted to the main hospital and can go home the same day. As you will have had sedation you will need to be accompanied by another adult who will take you home. You cannot drive yourself for 24 hours after sedation.

4)    Laparoscopy

Some patients may also need a further test called laparoscopy. This is a telescopic examination of the abdominal cavity, performed under a general anaesthetic with a rigid telescope passed through the abdominal wall. The procedure requires admission to the main wards overnight after the procedure.
 
Laparoscopy can detect signs of tumour spread inside the abdominal cavity that the other staging tests do not usually pick up. Some tissue samples may need to be collected which will take a few days to process.

Only some patients with tumours near the bottom end of the oesophagus require this investigation. If tumour spread is detected within the abdominal cavity, then the tumour is considered to be incurable by surgery, and a palliative treatment plan is therefore indicated.

After staging

Once the staging investigations are completed and all the results available, your case will be discussed in detail at the Multidisciplinary Upper GI Cancer meeting.

MDT

Diagnosis and treatment of cancer requires a team of experts called a multi-displinary team (or MDT for short). The MDT meeting is held weekly. A wide variety of cancer specialists are present at the meeting and we aim to come to a collective decision about the best way to proceed with your treatment. We will notify you and your GP as soon as possible after the meeting.

Some of the team you may come into contact with may include the following:

Gastroenterologist - This is a doctor who carries out diagnostic endoscopic procedures such as gastroscopy.

Upper GI Surgeon - This is a specialist who can access and diagnose cancers of the oesophagus or stomach. The surgeon will discuss different treatment options with you and drugs currently available. The surgeon will carry out any operations needed to remove cancer.
 
Registrar - This is a senior doctor who has chosen to specialise in this area of care and is getting specialist training in that area.

Upper GI Nurse Specialist - This is a nurse who is an expert in caring and supporting people with Upper GI problems. The Upper GI Nurse specialist will provide information to help you understand your treatment and will support you during your treatment.

The Radiologist - This is a doctor who is specially trained to interpret x-rays and special scans from which a diagnosis is made, and who is an expert in carrying out diagnostic tests.

The Pathologist - This is a doctor who is an expert in looking at cancer cells under a microscope and giving advice on how these cells can behave to guide decisions on treatment.

The Oncologist - This is a doctor who is an expert on non-surgical treatments for your type of cancer. They specialise in radiotherapy and chemotherapy.

Upper GI Dietician - This is a specialist who can offer advice and support on nutrition.

Macmillan Nurse - This is a nurse who specialises in symptom management. They can offer emotional and psychological support to patients and carers.

MDT co-ordinator - Is an essential member of the team who ensures that all your investigations and results are available for the MDT meeting, ensuring that you get a timely treatment plan.

Treatment Options

Benefits and possible risks to any treatment will be discussed once your course of treatment is identified.

1.) Potentially curative treatment

Surgery

An oesophagectomy is removal of part of the oesophagus. Depending on where the tumour is it may also be necessary to remove part of the stomach. After the affected part is removed the two remaining ends are then joined, usually by bringing the remaining stomach up into the chest.

It is a very big operation and involves about 2-3 weeks in hospital and a lengthy convalescent period afterwards.

Surgery with chemotherapy

Patients with more advanced (but still potentially curable) tumours may need a course of chemotherapy to shrink down the tumour before surgery is performed.

Such extra treatment is also a major undertaking and is carried out only at the Christies Hospital under care of a specialist oncology team. This will take several weeks after which time some of the staging investigations will need to be repeated to assess the effect of the treatment before finally committing to an operation.

Radical treatment without surgery

Sometimes patients who have potentially curable tumours may not be fit enough for a major operation, or just simply may not want to go through one. It is sometimes possible to consider aggressive treatment with radical radiotherapy or a combination of radical radio and chemotherapy.

The outcome of such treatment is difficult to predict since the tumour is not physically removed as it is by an operation, but such treatments may be considered appropriate for some patients.

2) Palliative treatment

Patients with incurable disease should not have an oesophagectomy or radical non-surgical treatment because the risks are too great and there is no realistic chance of any benefit to the patient.

Instead, palliative treatments should be considered to control troublesome symptoms. These include:

Stenting

A stent is a flexible metal tube which can be placed permanently inside the oesophagus to hold it open where the tumour has caused a narrowing (stricture). This enables the patient to eat and drink more normally, and can be placed without an operation, either telescopically or in the x- ray department. An overnight stay in hospital is usually required.

Palliative chemotherapy and radiotherapy

In patients who are still relatively fit, we may suggest a palliative course of chemo or radiotherapy. This may improve swallowing and can sometimes help increase lifespan. The treatment is intended however to be as gentle as possible and is not designed to provide a long-term cure. This treatment is carried out at the Christie Hospital.

Best supportive care

When the disease is found to be incurable, and possible palliative treatments have been discussed, some patients may prefer not to have any interventional treatment at all.
In such circumstances it is likely that their health will gradually deteriorate, and patients and their families will often need help and support at home. We will do our best to help by arranging appropriate social, physical and psychological support where it is needed.

Your treatment Plan:

 

 

 

 

 

 

Contacts and support

We hope that you have found this information leaflet useful and that it has helped answer some of your questions and concerns. We are aware that this is a very difficult time for both patients and their relatives. Your GP will have been made aware of your diagnosis already, and further support and advice is available through your GP, local hospices and community palliative care team and the upper GI cancer specialists here at Salford Royal Hospital.

Contact numbers

Upper GI Specialist Nurse - 0161 206 5062
Email: uppergi.nursingteam@nca.nhs.uk

Upper GI Surgical Secretaries:
0161 206 5472
0161 206 5744
0161 206 5128
0161 206 0449

Macmillan Cancer Support Centre
0161 206 1455

Questions