IF SYMPTOMS PERSIST

“My two assets my pen and my voice – and it had to be the esophagus.” – Christopher Hitchens (1949-2011), Anglo-American writer and journalist, Mortality (2012)

There are at least four alcoholic writers, (Poe, F. Scott Fitzgerald, Hemingway, Alan Watts) that I admire. The fifth is Christopher Hitchens who died of esopagheal cancer in 2012. It may not be difficult to link alcohol abuse and esophageal cancer because one type, squamous cell carcinoma, specifies alcohol as an irritant that repeatedly damages the food pipe lining. Another irritant is (from the chemicals of tobacco) smoking. "Usually armed with a glass of Scotch and an untipped Rothmans cigarette," was how the Sunday Times described the man. And Hitchens himself admitted in 2003 that his daily intake of alcohol was enough “to kill or stun the average mule.”

Risk Factors. Aside from alcohol and smoking, other risk factors are: male gender, obesity, drinking very hot liquids (us Asians: hot noodles! and ubiquitous tea), and GERD (gastro-esophageal reflux). One thing about GERD is that constant irritation of the esophageal lining leads to a precancerous stage called Barrett’s esophagus. This may eventually lead to the other type of esophageal cancer: adenocarcinoma.

Signs and Symptoms. The US National Institutes of Health lists six warning signs and symptoms: chest pain unrelated to eating, weight loss (without trying), vomiting blood, difficulty swallowing liquids or solids, heartburn, and regurgitation, or the backwards movement of food from the esophagus up the mouth.

Diagnosis.The tests that reveal esophageal cancer start with barium swallow. A thick liquid is taken which coats the esophagus. Xrays are then taken that allow scrutiny of the esophageal lining. In endoscopy, a fiberoptic tube with lens is slid down the throat and the esophagus is examined on video. Suspicious tissue can then be snipped for biopsy.

Staging Esophageal Cancer. Aside from cancer cell type, the other basis for treatment is the extent to which the cancer has spread. In Stage I, only the top layer of cells are involved. In Stage II, deep layers are now affected and may even include lymph nodes. In Stage III, the deepest layer of the esophageal wall has been invaded, including adjacent tissues and lymph nodes. In Stage IV, the cancer has spread to other parts of the body. There is no Stage V as Hitchens said.

Treatment. Stage I tumors have the best prognosis and these very small areas of the most superficial layer of the esophagus can be taken out endoscopically. For later stages, surgery may mean removing a portion of the esophagus (esophagectomy), and more radically, esophagogastrectomy (part of the food pipe plus the upper portion of the stomach). Interestingly, surgeons may patch missing sections with portions of the patient’s colon. Chemotherapy and radiation therapy may be combined with surgery for best results. Still, this is the cancer you’d wish on your worst enemies because by the time they find it hard to swallow, the cancer has pretty much gone to town. Hitchens himself wrote in 2010, while undergoing treatment, that he would be a “very lucky person to live another five years.” The over-all 5-year survival rate is indeed 15%. Most people die within the first year of diagnosis. Hitchens had a bit more but called it his “year of living dyingly.”

Dr. Pujalte is an orthopaedic surgeon. email [email protected]