Esophageal Cancer

Carcinoma is the most common cause of obstruction of the esophagus. Approximately half of all esophageal cancers are squamous cell carcinomas, which usually occur in the middle and lower two-thirds of the esophagus and are often associated with alcohol and tobacco use. The remaining 50% are adenocarcinomas, which generally begin in glandular tissue of the esophagus. Adenocarcinomas are associated with Barrett esophagus, a condition that occurs because of continued reflux of fluid from the stomach into the lower esophagus. Over time, reflux changes the cells at the end of the esophagus. Adenocarcinomas may invade the upper portion of the stomach.

Esophageal tumors begin as benign growths and grow rapidly because there is no serosal layer to inhibit growth. Because of the vast lymphatic network of the esophagus, esophageal cancers spread rapidly, both locally to regional lymph nodes and distantly to the lungs and liver. Complications include pulmonary problems that result from fistulae and aspiration; invasion of the tumor into major vessels, causing a massive hemorrhage; and obstruction and compression of the other structures in the head and neck. Although survival rates are improving, esophageal cancer is usually diagnosed at a late stage, and most patients die within 6 months of diagnosis. The American Cancer Society (ACS) estimates that 19,260 new cases of esophageal cancer will be diagnosed in 2021, and approximately 15,530 people will die from the disease. The 5-year survival rate for localized disease is 41%, and it is 18% for people with all stages of the disease.

Causes ⬆ ⬇

Although its etiology is unknown, experts believe that the exposure of the esophageal mucosa to toxins results in cellular changes that lead to cancer. For many years in the United States, the primary risk factors were alcohol and tobacco use. Alcohol and tobacco together seem to have a synergistic effect on esophageal cancer development; because alcohol is a solvent of fat-soluble compounds, it seems to allow carcinogens associated with tobacco to penetrate esophageal tissues more easily. Squamous cell carcinoma is the cancer type associated with smoking, alcohol use, poor nutrition, exposure to toxins, and infection. Recently, oral exposure of the human papillomavirus (HPV) infection has also been identified as a risk factor. In parts of the world where it is most common (Southeast Asia, the Middle East, and South Africa), the disease has been linked to nitrosamines and other contaminants in the soil. It has also been found to have a higher incidence in individuals whose diets are chronically deficient in fresh fruits, vegetables, vitamins, and proteins. Other risk factors include caustic injuries from lye ingestion and occupational exposure to perchloroethylene, which is used in the automotive and dry cleaning industries. Squamous cell carcinoma is also associated with drinking scalding beverages. Other types of esophageal cancer occur as well. In recent decades, there has been a progressive increase in adenocarcinoma of the esophagus related to gastroesophageal reflux disease (GERD) because of irritation from reflux of acid and bile. Obesity also is associated with adenocarcinoma, likely because of release of inflammatory mediators and the potential for metabolic syndrome.

Genetic Considerations ⬆ ⬇

Although the exact cause of esophageal cancer is not clear, environmental risk factors (such as smoking and alcohol consumption) appear to be predominant. Epidemiological studies in Chinese populations have found that variants in the low-molecular-weight polypeptide (LMP) genes, which function in immunological surveillance, increase risk for esophageal squamous cell carcinoma. These variants are likely inherited in autosomal recessive patterns, although the combination of genes and environmental factors is the most likely etiology of esophageal cancer.

Sex and Life Span Considerations ⬆ ⬇

Cancer of the esophagus usually occurs in men between the ages of 50 and 70 years. The disorder affects men in a 3:1 ratio to women.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

The ACS notes that adenocarcinoma is more common in White persons, and squamous cell carcinoma is more common in Black persons. Although treatment guidelines indicate that management of esophageal cancer should include surgery, Black persons are less likely than White persons to undergo surgery. Persons with low income and patients with no private insurance also have lower rates of surgery than other groups. Importantly, patients who do not receive surgery when indicated have higher mortality rates (Savitch et al., 2021), leading to health disparities for Black, low income, and uninsured patients. Gender and sexual minorities have several risk factors for esophageal cancer. They smoke more than their heterosexual and cisgender counterparts, increasing the risk for esophageal cancer. In addition, HPV is present in approximately 65% of gay men overall and 95% of gay men with HIV, also increasing risk. While little is known about health disparities due to esophageal cancer in sexual and gender minorities, factors such as poverty, stigma, and discrimination affect access to cancer screening and healthcare, which may lead to poorer outcomes.

Global Health Considerations ⬆ ⬇

The global incidence of esophageal cancer is 10 per 100,000 males and 5 per 100,000 females, but in some countries with high soil contamination, rates are as high as 800 per 100,000 individuals. In developing countries, females have a higher incidence of the condition than in developed countries, whereas the male incidence of esophageal cancer is approximately the same across countries. Esophageal cancer is more common in Iran, India, China, Southern Russia, and southern and eastern Africa than in the United States. Incidence is low in central Africa and South/Central America.

Assessment ⬆ ⬇

ASSESSMENT

History

Obtain an accurate history of risk factors, including race, cultural background, use of cigarettes and alcohol, pneumonia or HPV infections, and any esophageal problems. Dysphagia is usually experienced when at least 60% of the esophagus is occluded. Initially, it is mild and intermittent, and it occurs only with solid foods. Patients may report a sensation that “food is sticking in their throat.” Patients may describe hoarseness and a persistent cough. If the disease is untreated, symptoms soon progress to the inability to swallow semisoft or liquid food, and the patient experiences a severe weight loss, as much as 40 to 50 pounds over 2 to 3 months. Eventually, the patient is unable to swallow saliva. Also inquire about regurgitation, vomiting, chronic hiccups, odynophagia (painful swallowing), and dietary patterns. Patients may report pain radiating to the neck, jaw, ears, and shoulders.

Physical Examination

Dysphagia is the most common symptom and weight loss is the second most important symptom. Observe the patient's ability to swallow food. Note any chronic coughing and increased oral secretions. Listen to the patient's voice: Tumors in the upper esophagus can involve the larynx and cause hoarseness. Place the patient in the recumbent position; pain, hoarseness, coughing, and potential aspiration often occur in this position. Weigh the patient and determine the patient's strength and motion of the extremities. Severe weight loss and weakness are common symptoms. Except for weight loss, the physical examination may be normal.

Psychosocial

The patient needs to make a psychological adjustment to the diagnosis of a chronic illness that is often terminal, particularly if it is diagnosed at an advanced stage. Evaluate the patient for evidence of altered mood (e.g., depression or anxiety), and assess the coping mechanisms and support systems.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Esophagogastroduodenoscopy	Visualization of a normal esophagus and stomach	Direct visualization of tumor or fistula	Locates the tumor for a biopsy

Other Tests: Computed tomography scan, endoscopic ultrasound, thoracoscopy, laparoscopy, liver scan, bronchoscopy, magnetic resonance imaging, positive emission tomography

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisImbalanced nutrition: less than body requirements related to dysphagia as evidenced by weight loss

Outcomes

OutcomesNutritional status: Food and fluid intake; Nutrient status: Biochemical measures; Self management: Cancer; Knowledge: Cancer management

Interventions

InterventionsNutrition management; Nutrition therapy; Nutritional monitoring; Nutritional counseling; Fluid/electrolyte management; Medication management

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

Surgery, radiotherapy, chemotherapy, laser therapy, and endoscopic therapy are all options for treating cancer of the esophagus, and they may be used alone or in combination. Early stage patients may be treated with endoscopic therapies, such as endoscopic mucosal resection or endoscopic submucosal dissection. Trimodal therapy, which includes chemotherapy and radiotherapy (chemoradiation), followed by surgery is recommended for those who can tolerate this rigorous treatment regime. Preoperative chemotherapy followed by surgery has poorer patient outcomes than trimodal therapy. Two surgical procedures are commonly performed: esophagectomy (removal of all or part of the esophagus with a Dacron graft replacing the part that was removed) and esophagogastrectomy (resection of the lower part of the esophagus together with a proximal portion of the stomach, followed by anastomosis of the remaining portion of the esophagus and stomach). Postoperatively, monitor the nasogastric (NG) tube for patency. Expect some bloody drainage initially; within 24 to 48 hours, the drainage should change to a yellowish-green. Do not irrigate or reposition the NG tube without a physician's order. Fluid and electrolyte balance as well as intake and output should be monitored carefully. Monitor the patient who has had an anastomosis for signs and symptoms of leakage, which is most likely to occur 5 to 7 days postoperatively. These include low-grade fever, inflammation, accumulation of fluid, and early symptoms of shock (tachycardia, tachypnea).

For patients who are not candidates for surgery but rather for palliation, chemotherapy, radiotherapy, and laser therapy, reduce the size of the tumor and provide some relief to the patient. Usually, external beam radiation therapy is used. Normal esophageal tissue is also affected by the radiation, which is given over a 6- to 8-week period to minimize the side effects. Side effects include edema, epithelial desquamation, esophagitis, odynophagia, anorexia, nausea, and vomiting. Although radiation by itself does not cure esophageal cancer, it eases symptoms such as pain, bleeding, and dysphagia.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Chemotherapy	Varies by drug	Combinations: Paclitaxel and carboplatin; fluorouracil and cisplatin; fluorouracil and oxaliplatin; irinotecan and cisplatin; paclitaxel and fluoropyrimidine. Other types of chemotherapy: 5-fluorouracil, capecitabine, docetaxel, bleomycin, mitomycin, doxorubicin, methotrexate, vinorelbine, topotecan, mitoguazone, epirubicin, porfimer	Kills cancer cells; primary chemotherapy will not cure esophageal cancer unless surgery and/or radiation is also used; preoperatively, chemotherapy may be given to reduce tumor size; approximately 10%–40% of patients will have a significant shrinking of the tumor from these drugs

Independent

Carefully monitor the patient's nutritional intake and involve the patient in planning their diet. Maintain a daily record of caloric intake and weight. Monitor the skin turgor and mucous membranes to detect dehydration. Keep the head of the bed elevated at least 30 degrees to prevent reflux and pulmonary aspiration. If the patient is having problems swallowing saliva, keep a suction catheter with an oral suction at the bedside at all times. Teach the patient how to clear the mouth with the oral suction.

When appropriate, discuss expected preoperative and postoperative procedures, including information about x-rays, IV hydration, wound drains, NG tube and suctioning, and chest tubes. Immediately after surgery, implement strategies to prevent respiratory complications.

Provide emotional support. Focus on the patient's quality of life and discuss realistic planning and end-of-life care with the family. Involve the patient as much as possible in decisions concerning care. If the patient is terminally ill, encourage the significant others to involve the patient in discussions about funeral arrangements and terminal care, such as hospice care. Provide a referral to the patient to the American Cancer Society, support groups, and hospice care as appropriate.

Evidence-Based Practice and Health Policy

Findlay, M., Purvis, M., Venman, R., Luong, R., & Carey, S. (2020). Nutritional management of patients with oesophageal cancer throughout the treatment: Benchmarking against best practice. Supportive Care in Cancer, 28, 5963–5971.

The study benchmarks current nutrition management of patients with esophageal cancer against best practice recommendations. The authors identified critical points in the treatment trajectory where nutritional status is compromised and service gaps occur. The authors collected demographic, medical, and nutritional data from medical records of 37 patients who received curative treatment for esophageal cancer at a tertiary referral hospital.
The authors found that nutritional care was inconsistent across different treatment stages, weight declined over the course of treatment, and malnutrition led to unplanned readmission. While best practice recommendations were met for aspects of the immediate postoperative period, the authors identified service gaps that remained during preoperative and postdischarge care.

Documentation Guidelines ⬆ ⬇

Physical assessment data: Ability to eat and swallow, patency of airway, regularity of breathing, temperature, daily weights, breath sounds, intake and output, calorie counts
Chronological record of symptoms and response to interventions
The nature, location, duration, and intensity of pain; response to pain medication or other interventions
Patient's emotional response to a poor prognosis and treatment modalities

Discharge and Home Healthcare Guidelines ⬆

Medications

The patient should be able to state the name, purpose, dosage, schedule, common side effects, and importance of taking their medications.

Complications

Teach the patient to report any dysphagia or odynophagia, which may indicate a regrowth of the tumor. Teach the patient to inspect the wound daily for redness, swelling, discharge, or odor, which indicates the presence of infection.

Home Care

Teach family members to assist the patient with ambulation, splinting the incision, and chest physiotherapy. Educate caregivers on nutritional guidelines, food preparation, tube feedings, and parenteral nutrition, as appropriate. Inform the patient and family about the availability of high-caloric, high-protein, liquid supplements to maintain the patient's weight.

Resources

Provide patients with a list of resources for support after discharge: Visiting nurses, American Cancer Society, hospice, support groups.

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DRG Information ⬇

Introduction ⬆ ⬇