How Esophageal Cancer is Diagnosed
The first step in diagnosing esophageal cancer is to take a medical history and do a physical exam. Your doctor will ask about symptoms, like difficulty swallowing.
The next diagnostic step will be to do some imaging tests such as:
Barium swallow or upper GI X-rays : You will be asked to drink a barium solution. Then you will have a series of x-rays. This series of x-rays are used to evaluate the esophagus. Doctors usually ask for a barium swallow test first when they suspect esophageal problems.
CT scan (CAT scan or computed tomography) : This type of scan takes a series of detailed pictures of the esophagus at different angles.
A CT scan takes longer than a regular X-ray. You will have to lie very still on a table. This table will slide in and out of the scanner. Some people complain that they feel restless and confined. There are newer CT scanners in many hospitals and clinics that are faster and less confining.
The CT scan can help locate the cancer and determine how big it is. Your doctor will also use the CT scan to decide whether surgery is a good option for you.
MRI (magnetic resonance imaging): MRI scans are similar to CT scans except that they use radio waves and strong magnets to take pictures. MRIs are a little more uncomfortable than CT scans, because they involve an enclosed space. They also take longer. An MRI usually takes about an hour. Notify your physician if you’re claustrophobic.
PET scan (positron emission tomography): This scan requires a special radioactive sugar to be injected in your vein. The cancerous tissues then take up the sugar. That enables a scanner to easily see those areas. PET scans are useful for finding cancer that has spread.
Upper endoscopy/ EGD (esophagogastroduodenoscopy): These procedures use an endoscope, which is a thin, flexible tube with a light and video camera on the end. Your doctor will use it to examine the inside of your digestive tract. You will be given a sedative to make you sleep. The endoscope will be passed through your mouth, down your esophagus and into your stomach. If there are areas that look suspicious, a small piece of tissue can be removed through the endoscope. This is called a biopsy. If there is a cancerous mass blocking the opening of the esophagus, this test also allows your doctor to make the opening bigger. This will make food and liquids pass more easily.
Doctors use both kinds of endoscopy for staging purposes and for determining whether surgery is appropriate.
Biopsy: A suspicious finding on an endoscopy or on another type of scan may look like cancer. In a biopsy, your doctor removes a small piece of tissue from the area that looks suspicious. Then the tissue is examined under a microscope. The goal is to:
- Determine if cancer cells are present and
- Determine the type of cancer cells
Endoscopic ultrasound: An endoscopic ultrasound evaluates an esophageal cancer’s depth of penetration into the layers of muscle. This test uses a flexible tube called an endoscope. This tube is put through your mouth into your stomach. You will be given a sedative to make you sleepy or relaxed before you have an endoscopic ultrasound.
What is a pathology report?
In order to make a cancer diagnosis, a doctor needs to collect a sample of the tumor cells to be tested and examined in a lab by a pathologist. A pathologist is a doctor who identifies cancer and other diseases by studying cells under a microscope. After the pathologist studies a sample, he or she prepares a pathology report that explains the findings. Doctors use these reports to diagnosis and stage cancer.
What will be in the pathology report?
The pathology report provides all the pathologist’s findings. Your pathology report may include some or all of the following:
- Your identification information
- Your important medical history
- Details on how the sample or biopsy was taken
- Description of how the sample looked under the microscope
Size, color, grade, margins, node status, etc.
- Special tests or markers (hormone receptor status and HER2/neu status)
- A written summary of the full report
What do the words in my pathology report mean?
Here is a vocabulary list to help you through your pathology report:
Abnormal cells: cells that do not look or behave like healthy cells
Adenocarcinoma: cancer that develops in gland cells. Gland cells are found in the lining of some organs and create mucus, digestive juices, and other fluids.
Aggressive: fast growing
Angliolymphatic: means cancer has spread to the lymph nodes
Antibody: a protein produced by the immune system to fight foreign substances
Atypia: an abnormal cellular structure
Barrett’s esophagus: a condition where the lining of the lower part of the esophagus is full of abnormal cells. Reflux can cause Barrett’s esophagus. (This condition only increases your risk of esophageal cancer. If you already have esophageal cancer, it does not change your prognosis.)
Benign: not cancerous
Biopsy: a procedure to take a small sample of tissue
Cell Density: the number of cells in a single sample
Clean/ clear/ negative margins: the outer edge of the tissue sample does not contain cancer cells
Cytology: the study of a single cell or a small group of cells
Differentiation: how close the cells look to normal cells
Dysplasia: the presence of abnormal cells
Florescence In Situ Hybridization (FISH): a test used to find genetic mutations
Grade: how abnormal the cells look and how quickly the tumor is likely to grow
Granulomas: inflammation of the tissue, often from infection
HER2: human epidermal growth factor receptor two (HER2) is a protein sometimes involved in esophageal cancer. Too much of the protein on the surface of cells indicates increased aggressiveness.
Histology: the way the cells look under a microscope
Hyperplasia: increased cell production
Inconclusive: with the current sample and tests, it cannot be determined if cancer is present
Invasive: the cancer has spread to surrounding tissues
In Situ: abnormal cells have not spread; the abnormal cells are only where they started
Lymph node: lymph nodes filter lymphatic fluid and store white blood cells.
Metastasis: cancer that has spread to other parts of the body
Necrosis: cell death
Neoplasm: a growth made up of abnormal cells
Pathologist: a doctor who identifies diseases by studying cells and tissues under a microscope
Pleomorphic: able to change shape
Positive margins: the outer edge of the tissue sample does contain cancer cells
Stage: how advanced the cancer is
Stains: used to color the tissues and cells so the pathologist can see them better
Squamous cell carcinoma: cancer that begins in squamous cells. Squamous cells are found in the skin and the lining of the repertory and the digestive tracts.
Tissue Block: the sample of tissue removed during a biopsy or surgery
Vascular invasion: cancer cells are in the blood vessels
Once esophageal cancer has been diagnosed, it’s important to discuss what stage of cancer you have with your physician. The stage of esophageal cancer depends on how deep it has grown into the layers of the esophagus wall, lymph node involvement and if there is any spread of the tumor to other parts of the body. Staging also depends on if the cancer is a squamous cell carcinoma or adenocarcinoma. Knowing the stage helps your doctor plan the right course of treatment.
The TNM (tumor, node, and metastasis) staging system is used for all types of cancer, not just esophageal cancer. The letters TNM describe the amount and spread of cancer in your body.
- T: indicates how far the tumor has grown to outside organs and outside the wall of the esophagus
- N: indicates number of lymph nodes with cancer cells present
- M: indicates metastasis, which means that cancer has spread to other parts of the body
Using TNM, your doctor will stage your cancer into one of the following stages:
Stage 0 - This is the earliest stage of esophageal cancer. The cancer cells are only in the epithelium. This is the layer of cells lining your esophagus. At this stage the cancer has not spread to lymph nodes or other organs.
Stage I - The cancer has grown from the epithelium into the layers below but not any deeper. It has not spread to lymph nodes.
Stage II - Stage II is divided into levels A and B. In Stage IIA, the cancer has grown into the muscle layer. It may have also grown into the connective tissue that covers the outside of your esophagus. The cancer has not spread to lymph nodes or other organs. With IIB, the cancer may have also spread to one or two nearby lymph nodes.
Stage III - Stage III is divided into levels A, B, and C. In stage IIIA the cancer has grown into the layers below the epithelium. It may have also grown into the muscle layer. It has not expanded to the outer layer of tissue covering your esophagus. It may have spread to up to 7 lymph nodes nearby. It has not spread to any other organs. In stage IIIB, the cancer may have also grown into the outer layer of the esophagus. In stage IIIC, the cancer may have also spread to nearby tissues, blood vessels, or structures.
Stage IV - The cancer has spread to another part of the body and is in multiple lymph nodes.
There are three main ways that cancer spreads in your body. It can spread through:
- Tissue: Cancer invades nearby normal tissue.
- Lymph system: Cancer invades your lymph system and travels through your lymph vessels to other parts of your body.
- Blood: Cancer invades your veins and capillaries and travels through your bloodstream to other parts of your body.
The original tumor is called the primary tumor. When cancer cells break away from the primary tumor and travel to other places in your body, a secondary tumor can form. The name for this spreading process is metastasis.
The secondary tumor is the same kind of cancer as the primary tumor. For instance, if the cancer cells in your esophagus travel to your liver, it is called metastatic esophageal cancer. It is not called liver cancer.
Finding an Oncologist
One step of the esophageal cancer treatment journey is to find an oncologist (medical or surgical) who inspires trust. You may want to discuss this with your nurse navigator, primary care physician, or gastroenterologist). It may seem overwhelming to choose an oncologist. First, start with referrals from your primary care physician, specialist, or insurance carrier. Talk to family and friends who may have recommendations.
Here are some things to consider when choosing an oncologist:
- Is the oncologist board certified?
- How much experience does he or she have in treating esophageal cancer?
- Do you feel comfortable talking with this doctor? Does he or she listen well?
- Is the staff compassionate? Is the environment a good one or do you feel rushed?
- Where does this oncologist see patients? In which hospital?
- What are the office hours?
- What if you have an emergency? Can you call?
- Can this doctor be contacted after hours?
You will be spending a lot of time with the oncologist and staff nurses and technicians, so it’s important to feel comfortable with them.
- What kind of esophageal cancer do I have?
- Has my cancer spread beyond the primary site?
- What is the stage of my cancer?
- Are there other tests that need to be done before we can decide on treatment?
- Are there other doctors I need to see?
- How much experience do you have treating this type of cancer?
- What treatment choices do I have?
- What treatment(s) do you recommend and why?
- What is the goal of the treatment?
- What are the chances my cancer can be cured with these options?
- What are the risks or side effects that I should expect? How long are they likely to last?
- How quickly do we need to decide on treatment?
- What should I do to be ready for treatment?
- Will I have special nutritional needs due to the esophageal cancer?
- How long will treatment last? What will it involve? Where will it be done?
- What would we do if the treatment doesn't work or if the cancer recurs?
- What type of follow-up will I need after treatment?
- Where can I find more information and support?
Questions for Your Healthcare Team
If you’ve just been diagnosed with cancer, you may be confused and overwhelmed. You probably want answers, but you may not even know what questions to ask. As a cancer patient, being able to talk openly and honestly with your healthcare team is very important. Use these must-ask questions as a guide to start talking with your healthcare team.
What is my diagnosis?
This question may seem like a no-brainer, but in the rush of appointments, you may not receive a clear answer. If you are unsure of your diagnosis, ask your oncologist. Sometimes more specific tests are needed to make an exact diagnosis.
What is my prognosis? What stage is my cancer?
Knowing your prognosis can help you better prepare for the future and select your best treatment plan. In order to know the stage of your cancer, your doctor will need to do tests. These may include scans, genetic testing, and/or a biopsy. The answer to these questions may be difficult to hear. You may consider having a family member or friend with you at this appointment.
What are my treatment options? What would you recommend?
Ask your oncologist to explain all your treatment options, including possible side effects and cost. Ask your oncologist which treatment he or she recommends. If you are unsatisfied with your options, do not be afraid to seek a second opinion.
Am I eligible for a clinical trial?
Clinical trials help improve the standard of care for all cancer patients. Based on your situation, a clinical trial may also be your best treatment option. Each trial has its own eligibility requirements.
What are the possible short-term and long-term side effects of treatment? How will these affect my normal activities?
Always ask about short-term and long-term side effects before beginning treatment so you are prepared. You should also consider short-term and long-term side effects when deciding which treatment plan is best for you.
How can I manage these side effects?
Some side effects can be easily managed through diet, exercise, or over-the-counter medication. Other side effects may require prescription medication, occupational therapy, or physical therapy which your oncologist can prescribe as needed.
Will my ability to have children be affected? Is there anything I can do to preserve my fertility?
Some cancers and cancer treatments can affect your fertility, but you do have options. Before treatment, you may be able to freeze eggs or bank sperm. There may be steps you can take during treatment to protect your reproductive system as well. For more information, visit Fertile Hope at fertilehope.org.
How can I keep myself as healthy as possible during treatment?
Your own immune system plays a big part in your fight against cancer. It is important to stay as healthy as possible while undergoing cancer treatment.
Where can I find help with financial concerns?
Evaluate your financial situation as soon as possible. You will not want to deal with financial stress in the middle of treatment when you may not feel well.
Where can I find help with lodging or transportation?
When beginning cancer treatment, planning ahead is key. Some treatment centers have lodging coordinators or social workers to help you with the logistics of treatment. Ask your nurse navigator for assistance if you are having trouble finding lodging or transportation.
What will my follow-up care plan include?
After you finish treatment, make sure you and your oncologist create a follow-up care plan. You will need to check for recurrence. You may also need follow-up care for long term side effects.
When can I call myself a survivor?
According to the National Cancer Institute’s definition of a cancer survivor, “a person is considered to be a survivor from the time of diagnosis until the end of life.”