Esophageal Cancer

 

Am Fam Physician. 2017 Jan 1;95(1):22-28.

  Patient information: See related handout on esophageal cancer, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

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 tomography 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 recommendations for esophageal cancer screening.

Esophageal cancer is the eighth most common cancer worldwide. Nearly four out of five cases occur in nonindustrialized nations, with the highest rates in Asia and Africa.1,2 The National Cancer Institute estimates that in 2016, there will be 16,910 new cases and 15,910 deaths from esophageal cancer in the United States.3

Esophageal cancer is associated with a poor prognosis. Despite advances in diagnosis and treatment, the overall five-year survival rate for persons with esophageal cancer is 15% to 20% worldwide and in the United States.4

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.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Upper endoscopy should be the initial diagnostic procedure in patients with symptoms suggestive of esophageal cancer. Biopsy of suspicious lesions should be performed.

C

20, 21

Integrated positron emission tomography/computed tomography and endoscopic ultrasonography should be used for comprehensive staging of esophageal cancer.

C

2830

Endoscopic mucosal resection should be considered the first-line therapy for mucosal-based stage 0 or T1a tumors.

C

22, 31


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Upper endoscopy should be the initial diagnostic procedure in patients with symptoms suggestive of esophageal cancer. Biopsy of suspicious lesions should be performed.

C

20, 21

Integrated positron emission tomography/computed tomography and endoscopic ultrasonography should be used for comprehensive staging of esophageal cancer.

C

2830

Endoscopic mucosal resection should be considered the first-line therapy for mucosal-based stage 0 or T1a tumors.

C

22, 31


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

The two main subtypes of esophageal cancer are squamous cell carcinoma and adenocarcinoma. These subtypes account for more than 95% of malignant esophageal tumors. Rare subtypes of esophageal cancer, which are not discussed in this article, include lymphomas, melanomas, carcinoid tumors, and sarcomas.5

Squamous Cell Carcinoma of the Esophagus

Squamous cell carcinoma is the most common subtype of esophageal cancer outside of the United States, accounting for 90% of cases worldwide.6 The highest rates occur

The Authors

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MATTHEW W. SHORT, LTC, MC, USA, is director of medical education and research, designated institutional official, and a family physician endoscopist at Madigan Army Medical Center, Tacoma, Wash. He is also an associate professor of family medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md., and clinical assistant professor of family medicine at the University of Washington School of Medicine in Seattle....

KRISTINA G. BURGERS, MAJ, MC, USA, is a family physician endoscopist and faculty member at the Family Medicine Residency at Womack Army Medical Center, Fort Bragg, N.C.

VINCENT T. FRY, MAJ, MC, USA, is a family physician endoscopist at Ireland Army Community Hospital, Fort Knox, Ky. At the time the article was submitted, Dr. Fry was a family medicine gastroenterology/colonoscopy fellow and faculty member at the Family Medicine Residency at Madigan Army Medical Center.

Address correspondence to Matthew W. Short, LTC, MC, USA, Madigan Army Medical Center, MCHJ-CLF-C, 9040 Jackson Ave., Tacoma, WA 98341-1100. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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