Cancer Association of South Africa (CANSA)

Transcription

1 Cancer Assciatin f Suth Africa (CANSA) Fact Sheet On Oesphageal Cancer Intrductin The esphagus (cmmnly knwn as the gullet) is an rgan in humans (and ther vertebrates) which cnsists f a muscular tube thrugh which fd passes frm the pharynx t the stmach. During swallwing, fd passes frm the muth thrugh the pharynx int the esphagus and travels via peristalsis t the stmach. [Picture Credit: Oesphagus picture] This Latin wrd esphagus is derived frm the Greek wrd isphags, literally meaning entrance fr eating. In humans the esphagus is cntinuus with the laryngeal part f the pharynx at the level f the 6th cervical (neck) vertebra. The 0esphagus passes thrugh the psterir mediastinum in the thrax (chest) and enters the abdmen thrugh a hle in the diaphragm at the level f the 10th thracic (chest) vertebrae. It is usually abut 25cm lng, but variatins have been recrded depending n the individual s height. It is divided int the cervical, thracic and abdminal parts. Due t the lwer pharyngeal cnstrictr muscle, the entry f the esphagus t the stmach, pens nly when swallwing r vmiting. Oesphageal Cancer Oesphageal cancer is malignancy f the esphagus. There are varius subtypes, primarily squamus cell cancer and adencarcinma. Squamus cell cancer arises frm the cells that line the upper part f the esphagus. Adencarcinma arises frm glandular cells that are present at the junctin f the esphagus and stmach. Oesphageal cancers are typically carcinmas which arise frm the epithelium r surface lining f the esphagus. A general rule f thumb is that a cancer in the upper tw-thirds f the esphagus is a squamus cell carcinma and a cancer in the lwer ne-third f the esphagus is an adencarcinma. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 1

2 Incidence f Oesphageal Cancer in Suth Africa Accrding t the Natinal Cancer Registry (2012) the fllwing number f esphageal cancer cases were histlgically diagnsed in Suth Africa during 2012: Grup - Males 2012 Actual N f Cases Estimated Lifetime Risk Percentage f All Cancers All males :124 3,04% Asian males 16 1:374 1,92% Black males 808 1:113 6,92% Clured males 105 1:112 2,42% White males 193 1:154 0,96% Grup - Females 2012 Actual N f Cases Estimated Lifetime Risk Percentage f All Cancers All females 702 1:271 1,86% Asian females 12 1:645 1,11% Black females 544 1:239 3,30% Clured females 67 1:217 1,61% White females 78 1:481 0,49% The frequency f histlgically diagnsed cases f esphageal cancer in Suth Africa fr 2012 were as fllws (Natinal Cancer Registry, 2012): Grup - Males All males Asian males Black males Clured males White males Grup - Females All females Asian females Black females Clured females White females N.B. In the event that the ttals in any f the abve tables d nt tally, this may be the result f uncertainties as t the age, race r sex f the individual. The ttals fr all males and all females, hwever, always reflect the crrect ttals. Risk Factrs fr Oesphageal Cancer While risk factrs fr squamus cell carcinma (SCC) f the esphagus have been identified, namely tbacc use, alchl use, malnutritin, and infectin with human papillmavirus (HPV), the risk factrs assciated with esphageal adencarcinma (AC) are less well defined. The mst imprtant epidemilgical difference between squamus cell cancer and adencarcinma f the esphagus is the strng assciatin between gastresphageal reflux disease (GERD) and adencarcinma. Factrs that cause irritatin in the cells f the esphagus which increases the risk fr esphageal cancer include: Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 2

3 Drinking alchl - smking and drinking cmbined increase the risk f squamus cell carcinma (SCC) f the esphagus 20-fld Having bile reflux Chewing tbacc (smkeless tbacc) - The Internatinal Agency fr Research n Cancer (IARC) classifies smkeless tbacc and betel quid* (with r withut tbacc) as a cause f esphageal cancer. Studies int smkeless tbacc and esphageal cancer risk in the west have mainly been cnducted in the Nrdic cuntries, shwing a 60% increase in risk f esphageal cancer fr smkeless tbacc users Having difficulty swallwing because f an esphageal sphincter that will nt relax (achalasia) Drinking very ht liquids Other ptential risk factrs fr esphageal cancer include esphageal burns due t accidental r intentinal swallwing f caustic materials such as bleach Barret s Oesphagus - One f the strngest risk factrs fr adencarcinma f the esphagus is an acquired premalignant cnditin knwn as Barrett s esphagus (BO, r Barrett's metaplasia) Eating few fruits and vegetables - A recent meta-analysis f case-cntrl and chrt studies reprted a significant reductin in risk with higher cnsumptin f fruit and a nn-significant prtective rle f vegetable cnsumptin. A study published in December 2011 estimated that mre than 46% f esphageal cancer cases verall in men and arund 45% in wmen in the UK in 2010 were linked t peple eating fewer than five prtins a day (400g/day) f fruit and vegetables (Cancer Research UK) Eating fds preserved in lye, such as lutefisk, a Nrdic recipe made frm aged stckfish (air-dried whitefish) r dried/salted whitefish (klippfisk) and lye (lut) whitefish. Lye-cured lives is anther fd type in this categry Certain asthmatic medicines - drugs given t asthmatics such as?-agnists and aminphyllines als have the effect f relaxing the sphincter and this is the likely reasn fr the higher incidence f AC bserved in asthmatics Having gastr-esphageal reflux disease (GERD) Being bese Underging radiatin treatment t the chest r upper abdmen Smking - Eurpean studies shwed a fur-fld risk increase fr esphageal cancer verall amng smkers. The effect f smking is strnger fr SCC than adencarcinma (AC), with a recent chrt study shwing that current smkers have a nine-fld risk increase fr esphageal SCC and a fur-fld risk increase fr esphageal AC Race - squamus cell cancer f the esphagus is mre cmmn amng blacks than whites. Adencarcinma is mre cmmn in white men than men f ther races Vitamin Deficiencies - sme studies have linked esphageal cancer with deficiencies in beta cartene, vitamin E, selenium, and irn Histry f ther Illnesses - a variety f ther illnesses and medical cnditins have been assciated with an increased risk f esphageal cancer. These include: Cancers f the head, neck, r lungs Human papillmavirus (HPV) infectin Tylsis, a very rare inherited disease that causes excess skin grwth n the palms f the hands and the sles f the feet. Peple with this disease have a high risk f develping esphageal squamus cell cancer and shuld be screened regularly Oesphageal webs - abnrmal bands f tissue that extend inward int the esphagus making it difficult t swallw Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 3

4 Other risk factrs include: Being male Age - being between the ages f 45 and 70 (*) Betel quid is a cmbinatin f betel leaf, areca nut, and slaked lime. In many cuntries, tbacc is als added, and the prduct is knwn as gutka, ghutka, r gutkha. Other ingredients and flavurants are als added accrding t lcal preferences and custms (e.g., sweeteners; catechu; r spices such as cardamm, saffrn, clves, anise seeds, turmeric, and mustard). The fllwing cancers have been assciated with betel quid use: lip, muth, tngue, pharynx and esphagus. (Centers fr Disease Cntrl and Preventin). (May Clinic; Memrial Slan-Kettering Cancer Center; Natinal Fundatin fr Cancer Research; Cancer Research UK; Cancer.Net; MedicineNet.cm). Signs and Symptms f Oesphageal Cancer The fllwing are imprtant signs and symptms f esphageal cancer: Unintentinal weight lss - unintentinal weight lss can mean many things, but it is better t have it checked ut Pain when swallwing (dynphagia) - pain when swallwing is ne f the mst cmmn symptms f esphageal cancer. The thrat feels irritated r with pressure. This symptm is nt assciated with flu r flu-related illnesses. The pain r difficulty swallwing related with esphageal cancer des nt g away. Pain with swallwing is an minus sign Harseness - if the vice is harse, r the persn feels like he/she has t ften clear their thrat, it shuld get checked ut by a dctr Persistent cugh - having a cugh that des nt g away Heartburn - having heartburn - pain r burning sensatin behind the breast bne. Heart burn that ccurs ften r increasingly warrants a cnsultatin with a dctr Feeling like fd is stuck in thrat r chest - In certain cases f esphageal cancer, the esphagus narrws, thus reducing the amunt f space fds have t travel dwn t the stmach. The sensatin f fd being stuck in the thrat r chest is typical f esphageal cancer. It is generally nt nted until the esphageal lumen is narrwed t ne-half t ne-third f nrmal Hiccups with pain The presence f regular incidents f hiccups requires a visit t a dctr Cughing up f bld the bld is bright red in clur and nly a small quantity is vmited at any given time Dysphagia - the mst cmmn presenting cmplaint is dysphagia (difficulty in swallwing) which, due t esphageal elasticity, is generally nt nted until the esphageal lumen is narrwed t ne-half t ne-third f nrmal Cugh - cugh that is induced by swallwing is suggestive f lcal extensin int the trachea with resultant trachea-esphageal fistula and may be a sign f esphageal cancer Harseness - harseness may be a sign f recurrent laryngeal nerve invlvement due t extra-esphageal spread f cancer Metastatic disease - metastatic disease may present as malignant pleural effusin (fluid cllectin in the lungs) r ascites (fluid cllectin in the abdmen). Bne metastasis (cancer that has spread t the bnes) can be identified by pain invlving the affected site r by assciated hypercalcaemia (Abut.Cm Cancer; CancerNetwrk.Cm; WebMD; Natinal Fundatin fr Cancer Research; Cancer.Net; VCU Massy Cancer Center; Fred Hutchinsn Cancer Research Center). Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 4

5 Diagnsis f Oesphageal Cancer Screening - Regular screening tests t find esphageal cancer in peple withut symptms are nt ften used. Peple with Barrett's esphagus (see abve) may be advised t have endscpic examinatins (lking inside the esphagus thrugh a flexible, lighted tube) and bipsies (remval f a small amunt f tissue fr examinatin under a micrscpe) regularly t help find cancer early r t find changes that culd becme cancerus ver time. A diagnsis f esphageal cancer is usually made fllwing: Labratry studies which fcused n the evaluatin f nutritinal status Imaging studies that may include the fllwing: Barium swallw (very sensitive fr helping detect strictures and intraluminal masses, but nw rarely used) Oesphaggastrdudenscpy Endscpic ultrasngraphy (mst sensitive test fr T and N staging) Cmputed tmgraphy f the abdmen and chest (fr M staging and assessing invasin f adjacent structures) Brnchscpy (t help exclude invasin f the trachea r brnchi) Bne scan (fr patients with cmplaints suggestive f bne metastases) Laparscpy and thracscpy (fr staging reginal ndes) Psitrn emissin tmgraphy (PET fr elucidating hypermetablic fci f disease activity) (Medscape Reference; Cancer.Net). Types f Oesphageal Cancer There are tw main types f esphageal cancer. Bth types are diagnsed, treated, and managed in similar ways. The tw mst cmmn types are named fr hw the cancer cells lk under a micrscpe. Bth types begin in cells in the inner lining f the esphagus: Adencarcinma (AC) f the esphagus: This type is usually fund in the lwer part f the esphagus, near the stmach. Squamus cell carcinma (SCC) f the esphagus: This type is usually fund in the upper part f the esphagus. (Natinal Cancer Institute). Reducing the Risk fr Oesphageal Cancer The fllwing can assist in reducing the risk fr esphageal cancer: Quit smking r chewing tbacc. Jin the CANSA E-KickButt Prgramme Drink alchl in mderatin, if at all. The risk f varius types f cancer including cancer f the breast, cln, lung, kidney, liver and esphagus increases with the amunt f alchl ne drinks and the length f time ne has been drinking regularly. Alchl was classified as a Grup 1 carcingen by IARC in 1980 Eat mre fruits and vegetables. Add a variety f clurful fruits and vegetables t the diet. Try and eat at least five prtins f vegetables and fresh fruit (in seasn) every day Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 5

6 Maintain a healthy weight. If verweight r bese, talk t a dctr abut strategies t help lse weight Individuals with Barrett s Oesphagus shuld g fr screening every year (Life is Beautiful; May Clinic). Staging f Oesphageal Cancer The stage f a cancer is the mst significant factr when devising a treatment plan. Fr esphageal cancer, the system usually used t stage the disease is the TNM system (als knwn as the American Jint Cmmittee n Cancer, r AJCC, system).this system is based n three main variables: T, which refers t the size f the tumur; N, which describes hw far the cancer has spread t nearby lymph ndes; and M, which indicates whether the cancer has spread t distant rgans in the bdy r t lymph ndes nt lcated near the esphagus. The TNM system is used t categrise the cancer in stages 0 thrugh IV (0 4).The higher the stage number, the mre the cancer has spread. Sme dctrs als divide the stages int letters (fr example, IIA r IIB) t further clarify the extent f the cancer. There are 4 stages f tumur size in esphageal cancer. They are: T1 means the tumur has grwn n further than the layer f supprtive tissue T2 means the tumur has grwn int the muscle layer f the wall f the esphagus T3 means the tumur has grwn int the membrane cvering the utside f the esphagus T4 means the tumur has grwn int ther rgans r bdy structures next t the fd pipe. It is divided int T4a and T4b. T4a means that the cancer has grwn int the tissue cvering the lungs (pleura), the uter cvering f the heart (pericardium), r the muscle at the bttm f the rib cage (diaphragm). T4b means that the cancer has spread int ther nearby structures such as the windpipe (trachea), a spinal bne (vertebra) r a majr bld vessel (the arta). In cancer f the esphagus, the N stages refer t lymph ndes that surrund the fd pipe (the reginal lymph ndes). There are 4 pssible stages: N0 means there are n lymph ndes cntaining cancer cells N1 means there are cancer cells in 1 r 2 nearby lymph ndes N2 means there are cancer cells in 3 t 6 nearby lymph ndes N3 means there are cancer cells in 7 r mre nearby lymph ndes There are tw stages f metastasis M0 means there is n cancer spread t ther rgans M1 means the cancer has spread t ther parts f the bdy (Natinal Fundatin fr Cancer Research; Cancer Research UK) Prgnsis (Outlk) The likelihd f being cured f cancer depends in large part n the stage f the cancer at the time it is diagnsed. Frm 80% t 90% f patients with the earliest stage f esphageal cancer can expect t be alive and cancer free 5 years after treatment. Hwever, since the Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 6

7 typical esphageal cancer is discvered at a relatively advanced stage, the verall success rate in curing esphageal cancer is disappinting (The sciety f Thracic Surgens). Survival rates are slwly imprving as esphageal cancers are being detected earlier and mre effective treatments are develped, but even s they remain pr. Overall, abut 40 per cent f peple are still alive ne year after diagnsis, but currently nly abut 1 in 8 survive t 5 years. Survival rates are, f curse, better fr thse with early stage disease (MacNair). Treatment f Oesphageal Cancer As with mst cancers, if a case f esphageal cancer is fund, the first step is t wrk ut what type f cancer it is and hw far it has spread. This is called staging, and it helps t predict hw the cancer is likely t prgress and which treatments are mst apprpriate Treatments that may be ffered include: Surgery - what exactly is dne will depend n where the tumur is, the stage f the cancer and the persn's general level f fitness. In early stage cancer the lining f the esphagus may simply be remved, but mre ften part (r all) f the esphagus is taken away. Often nearby lymph ndes and ther tissues must be remved t. The esphagus is then repaired s the patient can swallw fd. Smetimes a sectin f the lwer intestine may be used t replace the remved part f the esphagus r t bypass a whle area if the tumur is t large. During the peratin, the surgen will examine the esphagus and surrunding area. Sme f the lymph ndes will be remved frm arund the esphagus. The dctr will send the lymph ndes t the labratry t check t see if they cntain cancer cells. This helps the dctr t knw the stage f the cancer. Endscpic mucsal resectin (EMR) - if the patient has high grade Barrett's esphagus, r a very early stage cancer which is nly n the lining f the esphagus (the mucsal layer), it may be pssible t remve it using endscpic mucsal resectin (EMR). High grade Barrett's esphagus means that sme f the cells are very abnrmal. If left untreated, these cells may develp int an invasive cancer. Fr this prcedure, the dctr puts a tube called an endscpe dwn the patient s thrat. The endscpe cntains a camera s the dctr can see inside the bdy. The endscpe can be used t inject fluid int the layer f cells belw the cancer r abnrmal area, which makes it stand ut frm the rest f the tissue. Then a thin wire (snare) is used t remve the area. The mst cmmn side effects are bleeding and a narrwing f the esphagus, which can happen sme time after the prcedure. There is a very small risk f tearing the esphageal wall. The patient may als have phtdynamic therapy r radifrequency ablatin after EMR, t try t destry any abnrmal areas r cancer cells that may be left. Chemtherapy - relieves symptms and may slw cancer grwth. Giving chemtherapy befre surgery is called ne adjuvant chemtherapy. This is cmmnly used fr treating esphageal cancer. The chemtherapy can shrink the cancer, making it easier t remve. It als helps reduce the chances f the cancer cming back. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 7

8 If there is cancer f the lwer esphagus r where the esphagus meets the stmach (gastr-esphageal junctin) chemtherapy may be rdered after surgery, as well as befre. This als helps t lwer the chances f the cancer cming back. If the esphageal cancer has spread t ther parts f the bdy (advanced esphageal cancer) the patient may be given chemtherapy n its wn. This may help t cntrl r shrink the cancer and reduce symptms. Raditherapy - may be used t shrink a tumur befre surgery. It may be given n its wn, in cmbinatin with chemtherapy r after surgery t try t prevent recurrence. A patient may be given raditherapy alngside chemtherapy (chemradiatin) befre, r instead f, surgery. Or in sme cases, the patient may have raditherapy n its wn if he/she is unable t have chemtherapy r surgery. In the case f advanced esphageal cancer, the patient is mst likely t have raditherapy n its wn t help cntrl the cancer and relieve symptms. Raditherapy is painless t have, althugh it may make the thrat sre as the curse f treatment ges n. It is usual t have this treatment as an utpatient. The length f the curse f raditherapy treatment will depend n the size and type f esphageal cancer the patient has. Usual treatment is fr a few minutes every day, ver a few weeks. Smetimes raditherapy is given frm inside the bdy. This is knwn as internal raditherapy r brachytherapy. Fr esphageal cancer, this means having a radiactive surce put dwn yur thrat and int the fd pipe. The dctr may use a flexible tube knwn as an endscpe t get the radiactive surce in the right place. A patient is mst likely t have this treatment if he/she has an advanced cancer that is making it difficult t swallw. Cmbined chemtherapy and raditherapy - In sme cases, a patient may have chemtherapy and raditherapy tgether. This is called chemradiatin. A patient may have it befre surgery t help shrink the cancer, making it easier t remve. If a patient is unable t have surgery, r d nt want it, he/she may have chemradiatin n its wn. Particularly if they have squamus cell cancer near the tp f the esphagus. Sme studies have shwn that chemradiatin can be as gd as surgery fr this type f cancer. Chemradiatin is quite an intensive treatment and there are side effects. The dctr will cnsider the patient s general health befre deciding if this treatment is an ptin. Laser treatment - if the cancer is blcking the esphagus and making it difficult t swallw, the patient may need treatment t clear the blckage. Smetimes laser treatment is used t burn away the tumur. This may help t reduce the size f the tumur and relieve symptms but is nt curative. Laser treatment may be cmbined with the use f a light-sensitive drug (knwn as pht-dynamic therapy r PDT). Insertin f a stent - a rigid tube is placed in the esphagus t help keep it pen and allw fd t pass thrugh t the stmach. It can help deal with symptms but des nt treat the cancer itself Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 8

9 Bilgical (Immun-) therapies - made frm chemicals that ccur naturally in the bdy such as antibdies, r substances that cunteract the effect f the prtein signalling mlecules which naturally stimulate grwth f the cells (knwn as grwth factr blckers). Anther type f bilgical therapy is a vaccine, which can stimulate the immune system t identify cancerus cells and destry them. Bilgical therapy is nt ften used, hwever, if the tumur is in the area where the esphagus jins the stmach (esphaggastric junctin), dctrs smetimes use a bilgical therapy drug called trastuzumab (Herceptin). Tw main types f cancer affect the esphagus, a muscular tube thrugh which fd passes frm the muth t the stmach: squamus cell carcinma (cancer that begins in flat cells lining the esphagus) and adencarcinma (cancer that begins in cells that make and release mucus, which are usually assciated with ectpic gastric mucsa). Oesphageal cancer is mre cmmn in men than in wmen. The 5-year relative survival rate fr patients with esphageal cancer is 40% fr patients with lcalised disease; 22% fr reginal disease; and 4% fr metastatic disease. Surgery remains the mst cmmn treatment fr esphageal cancer, thugh chemtherapy, radiatin, and immuntherapy may als be used. The tw immuntherapies apprved fr esphageal cancer are trastuzumab and ramucirumab. Several appraches t immuntherapy fr esphageal cancer have shwn prmise in early clinical trials. These treatments can be brken int 5 main categries: checkpint inhibitrs/immune mdulatrs, adptive cell transfer, mnclnal antibdies, therapeutic vaccines, and cytkines. Are yu a patient r caregiver interested in learning mre abut cancer immuntherapy treatment and clinical trials? Immuntherapy has the ptential t imprve the utlk fr patients and families affected by the disease and bring us ever clser t effective, lasting cures fr esphageal cancer. That's why CRI supprts scientific research being dne t advance the ptential f immuntherapies fr esphageal cancers. Recent develpments include the analysatin f NY-ESO-1 cancer-testis (CT) antigen expressin in esphageal cancer, seeking t crrelate this expressin with disease stage and clinical utcme in a trial f 123 esphageal cancer specimens with a 33% expressin rate. The high expressin frequency f NY-ESO-1 indicates this as a feasible vaccine target in esphageal cancer. Additinally, clinical investigatrs and clleagues in Japan have reprted that a vaccine cmpsed f the NY-ESO-1f lng peptide administered with the immune stimulants culd elicit integrated immune respnses including antibdies, CD4+ helper T cells, and CD8+ killer T cells in nine ut f the ten patients enrlled in a phase I clinical trial, stabilizing the disease fr three patients, including ne with esphageal cancer. The strng results f this study suggest that esphageal vaccines using immuntherapy-treated lng peptides are a prmising therapy ptin fr esphageal cancer. (Cancer Research Institute). Phtdynamic Therapy (PDT) - this treatment invlves the use f lw pwered lasers cmbined with a light sensitive drug t destry cancer cells. PDT is a relatively new treatment, and yu may need t have it repeated a number f times. A patient may be given this: as a treatment t try t prevent high grade Barrett's esphagus develping int cancer, if yu are unable t have an endscpic mucsal resectin (EMR) r surgery Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 9

10 after EMR fr high grade Barrett's r very early esphageal cancer, t treat any abnrmal r cancerus cells left behind t destry part f a tumur and imprve swallwing when advanced esphageal cancer is making this difficult Radifrequency ablatin (RFA) If a patient has high grade Barrett's esphagus, he/she may have RFA either n its wn r after an endscpic mucsal resectin (EMR). RFA uses heat made by radi waves t destry the abnrmal cells. Radifrequency is a type f electrical energy. And ablatin means destrying cmpletely. A tube with a camera (endscpe) is passed dwn the thrat int the esphagus. A small balln r prbe is then guided t the area f abnrmal cells. A few quick pulses f electrical energy is given t destry the abnrmal cells n the inside f the esphagus. RFA may als be used after EMR fr a very early stage esphageal cancer. Argn plasma cagulatin (APC) - APC is smetimes recmmended after EMR r as a treatment if swallwing remains difficult. Using an endscpe, a prbe is placed clse t the area t be treated. Using a cmbinatin f argn gas and electricity, the dctr can destry the cancer. (MacNair; Cancer Research UK; MacMillan Cancer Supprt; May Clinic). Changing f Lifestyle Fllwing Oesphageal Cancer Diagnsis Lifestyle changes fllwing an esphageal cancer diagnsis can be helpful in a variety f imprtant ways: Strengthening the bdy s that ne can withstand sme f the rigrs f treatment Optimising the functin f the immune system t aid in the fight against cancer Imprving ne s emtinal utlk, s ne can enjy life t the fullest, even during treatment fr esphageal cancer Making healthful chices that will help t avid ther medical prblems that culd cmplicate health General Guidelines Stp smking - Smking is a knwn risk factr fr many cancers. It is never t late t stp smking. Jin CANSA s e-kickbutt Prgramme r ask a dctr abut prgrammes t help stp smking. Reduce the risk f infectin - T decrease the risk f infectin, avid expsure t bacteria and viruses: Try t avid crwds, especially during cld and flu seasn Ask a dctr abut immunisatin against the flu and pneumnia Wash hands thrughly and ften. Hand washing is the mst effective methd f decreasing the chance f catching clds and flu. Yu may wish t carry hand sanitizer with yu fr ccasins when washing is nt cnvenient. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 10

11 Fllw a Nutritius Diet - Eating a healthful diet may help avid ther medical cnditins linked t pr nutritin. Because cancer itself and sme cancer treatment may have a dulling effect n ne s appetite, it s imprtant that ne makes the mst f the calries taken in. Strngly cnsider cnsulting a registered dietician (RD) t help learn mre abut the best kinds f fds t eat and hw t eat ther less healthful fds in mderatin. Rest when tired - The treatments fr cancer can add t the fatigue patients may experience. Fatigue is the mst frequently experienced symptm f cancer and cancer treatments. The fatigue can range frm just feeling tired t cmplete and utter exhaustin. It is imprtant t allw the bdy time t rest. This will help the bdy have the strength t heal itself. Studies have shwn a relatinship between fatigue and an increased mrbidity f cancer and cancer treatments as a result f fatigue's adverse effect n appetite, diminished quality f life, and lss f hpe. Seek supprt - The diagnsis f cancer is a life-defining event that is difficult t handle fr anyne. Facing the uncertainty f a serius disease, feeling anxius abut hw ne will feel during treatment, and wrrying abut the impact f bth the diagnsis and treatment can take a devastating tll that n ne shuld have t tackle n their wn. Try t have access t the fllwing: Family Friends Religius cmmunity Empathetic supprt grups fr peple with yur type f cancer Prfessinal supprt (scial wrkers, psychlgists, and/r psychiatrists wh are trained t help supprt cancer patients and their families) Peple wh allw themselves t seek help while they are recvering frm cancer can ften maintain better emtinal equilibrium, which will help them face the challenges f cancer and its treatment (Winchester Hspital). Abut Clinical Trials Clinical trials are research studies that invlve peple. These studies test new ways t prevent, detect, diagnse, r treat diseases. Peple wh take part in cancer clinical trials have an pprtunity t cntribute t scientists knwledge abut cancer and t help in the develpment f imprved cancer treatments. They als receive state-f-the-art care frm cancer experts. Types f Clinical Trials Cancer clinical trials differ accrding t their primary purpse. They include the fllwing types: Treatment - these trials test the effectiveness f new treatments r new ways f using current treatments in peple wh have cancer. The treatments tested may include new drugs r new cmbinatins f currently used drugs, new surgery r radiatin therapy techniques, and vaccines r ther treatments that stimulate a persn s immune system t fight cancer. Cmbinatins f different treatment types may als be tested in these trials. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 11

12 Preventin - these trials test new interventins that may lwer the risk f develping certain types f cancer. Mst cancer preventin trials invlve healthy peple wh have nt had cancer; hwever, they ften nly include peple wh have a higher than average risk f develping a specific type f cancer. Sme cancer preventin trials invlve peple wh have had cancer in the past; these trials test interventins that may help prevent the return (recurrence) f the riginal cancer r reduce the chance f develping a new type f cancer Screening - these trials test new ways f finding cancer early. When cancer is fund early, it may be easier t treat and there may be a better chance f lng-term survival. Cancer screening trials usually invlve peple wh d nt have any signs r symptms f cancer. Hwever, participatin in these trials is ften limited t peple wh have a higher than average risk f develping a certain type f cancer because they have a family histry f that type f cancer r they have a histry f expsure t cancer-causing substances (e.g., cigarette smke). Diagnstic - these trials study new tests r prcedures that may help identify, r diagnse, cancer mre accurately. Diagnstic trials usually invlve peple wh have sme signs r symptms f cancer. Quality f life r supprtive care - these trials fcus n the cmfrt and quality f life f cancer patients and cancer survivrs. New ways t decrease the number r severity f side effects f cancer r its treatment are ften studied in these trials. Hw a specific type f cancer r its treatment affects a persn s everyday life may als be studied. Where Clinical Trials are Cnducted Cancer clinical trials take place in cities and twns in dctrs ffices, cancer centres and ther medical centres, cmmunity hspitals and clinics. A single trial may take place at ne r tw specialised medical centres nly r at hundreds f ffices, hspitals, and centres. Each clinical trial is managed by a research team that can include dctrs, nurses, research assistants, data analysts, and ther specialists. The research team wrks clsely with ther health prfessinals, including ther dctrs and nurses, labratry technicians, pharmacists, dieticians, and scial wrkers, t prvide medical and supprtive care t peple wh take part in a clinical trial. Research Team The research team clsely mnitrs the health f peple taking part in the clinical trial and gives them specific instructins when necessary. T ensure the reliability f the trial s results, it is imprtant fr the participants t fllw the research team s instructins. The instructins may include keeping lgs r answering questinnaires. The research team may als seek t cntact the participants regularly after the trial ends t get updates n their health. Clinical Trial Prtcl Every clinical trial has a prtcl, r actin plan, that describes what will be dne in the trial, hw the trial will be cnducted, and why each part f the trial is necessary. The prtcl als includes guidelines fr wh can and cannt participate in the trial. These guidelines, called eligibility criteria, describe the characteristics that all interested peple must have befre Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 12

13 they can take part in the trial. Eligibility criteria can include age, sex, medical histry, and current health status. Eligibility criteria fr cancer treatment trials ften include the type and stage f cancer, as well as the type(s) f cancer treatment already received. Enrlling peple wh have similar characteristics helps ensure that the utcme f a trial is due t the interventin being tested and nt t ther factrs. In this way, eligibility criteria help researchers btain the mst accurate and meaningful results pssible. Natinal and Internatinal Regulatins Natinal and internatinal regulatins and plicies have been develped t help ensure that research invlving peple is cnducted accrding t strict scientific and ethical principles. In these regulatins and plicies, peple wh participate in research are usually referred t as human subjects. Infrmed Cnsent Infrmed cnsent is a prcess thrugh which peple learn the imprtant facts abut a clinical trial t help them decide whether r nt t take part in it, and cntinue t learn new infrmatin abut the trial that helps them decide whether r nt t cntinue participating in it. During the first part f the infrmed cnsent prcess, peple are given detailed infrmatin abut a trial, including infrmatin abut the purpse f the trial, the tests and ther prcedures that will be required, and the pssible benefits and harms f taking part in the trial. Besides talking with a dctr r nurse, ptential trial participants are given a frm, called an infrmed cnsent frm, that prvides infrmatin abut the trial in writing. Peple wh agree t take part in the trial are asked t sign the frm. Hwever, signing this frm des nt mean that a persn must remain in the trial. Anyne can chse t leave a trial at any time either befre it starts r at any time during the trial r during the fllw-up perid. It is imprtant fr peple wh decide t leave a trial t get infrmatin frm the research team abut hw t leave the trial safely. The infrmed cnsent prcess cntinues thrughut a trial. If new benefits, risks, r side effects are discvered during the curse f a trial, the researchers must infrm the participants s they can decide whether r nt they want t cntinue t take part in the trial. In sme cases, participants wh want t cntinue t take part in a trial may be asked t sign a new infrmed cnsent frm. New interventins are ften studied in a stepwise fashin, with each step representing a different phase in the clinical research prcess. The fllwing phases are used fr cancer treatment trials: Phases f a Clinical Trial Phase 0. These trials represent the earliest step in testing new treatments in humans. In a phase 0 trial, a very small dse f a chemical r bilgic agent is given t a small number f peple (apprximately 10-15) t gather preliminary infrmatin abut hw the agent is prcessed by the bdy (pharmackinetics) and hw the agent affects the bdy (pharmacdynamics). Because the agents are given in such small amunts, n infrmatin is btained abut their safety r effectiveness in treating cancer. Phase 0 trials are als called micr-dsing studies, explratry Investigatinal New Drug (IND) trials, r early phase Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 13

14 I trials. The peple wh take part in these trials usually have advanced disease, and n knwn, effective treatment ptins are available t them. Phase I (als called phase 1). These trials are cnducted mainly t evaluate the safety f chemical r bilgic agents r ther types f interventins (e.g., a new radiatin therapy technique). They help determine the maximum dse that can be given safely (als knwn as the maximum tlerated dse) and whether an interventin causes harmful side effects. Phase I trials enrl small numbers f peple (20 r mre) wh have advanced cancer that cannt be treated effectively with standard (usual) treatments r fr which n standard treatment exists. Althugh evaluating the effectiveness f interventins is nt a primary gal f these trials, dctrs d lk fr evidence that the interventins might be useful as treatments. Phase II (als called phase 2). These trials test the effectiveness f interventins in peple wh have a specific type f cancer r related cancers. They als cntinue t lk at the safety f interventins. Phase II trials usually enrl fewer than 100 peple but may include as many as 300. The peple wh participate in phase II trials may r may nt have been treated previusly with standard therapy fr their type f cancer. If a persn has been treated previusly, their eligibility t participate in a specific trial may depend n the type and amunt f prir treatment they received. Althugh phase II trials can give sme indicatin f whether r nt an interventin wrks, they are almst never designed t shw whether an interventin is better than standard therapy. Phase III (als called phase 3). These trials cmpare the effectiveness f a new interventin, r new use f an existing interventin, with the current standard f care (usual treatment) fr a particular type f cancer. Phase III trials als examine hw the side effects f the new interventin cmpare with thse f the usual treatment. If the new interventin is mre effective than the usual treatment and/r is easier t tlerate, it may becme the new standard f care. Phase III trials usually invlve large grups f peple (100 t several thusand), wh are randmly assigned t ne f tw treatment grups, r trial arms : (1) a cntrl grup, in which everyne in the grup receives usual treatment fr their type f cancer, r 2) an investigatinal r experimental grup, in which everyne in the grup receives the new interventin r new use f an existing interventin. The trial participants are assigned t their individual grups by randm assignment, r randmisatin. Randmisatin helps ensure that the grups have similar characteristics. This balance is necessary s the researchers can have cnfidence that any differences they bserve in hw the tw grups respnd t the treatments they receive are due t the treatments and nt t ther differences between the grups. Randmisatin is usually dne by a cmputer prgram t ensure that human chices d nt influence the assignment t grups. The trial participants cannt request t be in a particular grup, and the researchers cannt influence hw peple are assigned t the grups. Usually, neither the participants nr their dctrs knw what treatment the participants are receiving. Peple wh participate in phase III trials may r may nt have been treated previusly. If they have been treated previusly, their eligibility t participate in a specific trial may depend n the type and the amunt f prir treatment they received. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 14

15 In mst cases, an interventin will mve int phase III testing nly after it has shwn prmise in phase I and phase II trials. Phase IV (als called phase 4). These trials further evaluate the effectiveness and lng-term safety f drugs r ther interventins. They usually take place after a drug r interventin has been apprved by the medicine regulatry ffice fr standard use. Several hundred t several thusand peple may take part in a phase IV trial. These trials are als knwn as pst-marketing surveillance trials. They are generally spnsred by drug cmpanies. Smetimes clinical trial phases may be cmbined (e.g., phase I/II r phase II/III trials) t minimize the risks t participants and/r t allw faster develpment f a new interventin. Althugh treatment trials are always assigned a phase, ther clinical trials (e.g., screening, preventin, diagnstic, and quality-f-life trials) may nt be labelled this way. Use f Placebs The use f placebs as cmparisn r cntrl interventins in cancer treatment trials is rare. If a placeb is used by itself, it is because n standard treatment exists. In this case, a trial wuld cmpare the effects f a new treatment with the effects f a placeb. Mre ften, hwever, placebs are given alng with a standard treatment. Fr example, a trial might cmpare the effects f a standard treatment plus a new treatment with the effects f the same standard treatment plus a placeb. Pssible benefits f taking part in a clinical trial The benefits f participating in a clinical trial include the fllwing: Trial participants have access t prmising new interventins that are generally nt available utside f a clinical trial. The interventin being studied may be mre effective than standard therapy. If it is mre effective, trial participants may be the first t benefit frm it. Trial participants receive regular and careful medical attentin frm a research team that includes dctrs, nurses, and ther health prfessinals. The results f the trial may help ther peple wh need cancer treatment in the future. Trial participants are helping scientists learn mre abut cancer (e.g., hw it grws, hw it acts, and what influences its grwth and spread). Ptential harms assciated with taking part in a clinical trial The ptential harms f participating in a clinical trial include the fllwing: The new interventin being studied may nt be better than standard therapy, r it may have harmful side effects that dctrs d nt expect r that are wrse than thse assciated with standard therapy. Trial participants may be required t make mre visits t the dctr than they wuld if they were nt in a clinical trial and/r may need t travel farther fr thse visits. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 15

16 Crrelative research studies, and hw they are related t clinical trials In additin t answering questins abut the effectiveness f new interventins, clinical trials prvide the pprtunity fr additinal research. These additinal research studies, called crrelative r ancillary studies, may use bld, tumur, r ther tissue specimens (als knwn as bispecimens ) btained frm trial participants befre, during, r after treatment. Fr example, the mlecular characteristics f tumur specimens cllected during a trial might be analysed t see if there is a relatinship between the presence f a certain gene mutatin r the amunt f a specific prtein and hw trial participants respnded t the treatment they received. Infrmatin btained frm these types f studies culd lead t mre accurate predictins abut hw individual patients will respnd t certain cancer treatments, imprved ways f finding cancer earlier, new methds f identifying peple wh have an increased risk f cancer, and new appraches t try t prevent cancer. Clinical trial participants must give their permissin befre bispecimens btained frm them can be used fr research purpses. When a clinical trial is ver After a clinical trial is cmpleted, the researchers lk carefully at the data cllected during the trial t understand the meaning f the findings and t plan further research. After a phase I r phase II trial, the researchers decide whether r nt t mve n t the next phase r stp testing the interventin because it was nt safe r effective. When a phase III trial is cmpleted, the researchers analyse the data t determine whether the results have medical imprtance and, if s, whether the tested interventin culd becme the new standard f care. The results f clinical trials are ften published in peer-reviewed scientific jurnals. Peer review is a prcess by which cancer research experts nt assciated with a trial review the study reprt befre it is published t make sure that the data are sund, the data analysis was perfrmed crrectly, and the cnclusins are apprpriate. If the results are particularly imprtant, they may be reprted by the media and discussed at a scientific meeting and by patient advcacy grups befre they are published in a jurnal. Once a new interventin has prven safe and effective in a clinical trial, it may becme a new standard f care. (Natinal Cancer Institute). Medical Disclaimer This Fact Sheet is intended t prvide general infrmatin nly and, as such, shuld nt be cnsidered as a substitute fr advice, medically r therwise, cvering any specific situatin. Users shuld seek apprpriate advice befre taking r refraining frm taking any actin in reliance n any infrmatin cntained in this Fact Sheet. S far as permissible by law, the Cancer Assciatin f Suth Africa (CANSA) des nt accept any liability t any persn (r his/her dependants/estate/heirs) relating t the use f any infrmatin cntained in this Fact Sheet. Whilst the Cancer Assciatin f Suth Africa (CANSA) has taken every precautin in cmpiling this Fact Sheet, neither it, nr any cntributr(s) t this Fact Sheet can be held respnsible fr any actin (r the lack theref) taken by any persn r rganisatin wherever they shall be based, as a result, direct r therwise, f infrmatin cntained in, r accessed thrugh, this Fact Sheet. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 16

17 Surces and References Abut.Cm Cancer Cancer.Net CancerNetwrk.Cm Cancer Research Institute Cancer Research UK Centers fr Disease Cntrl and Preventin Fred Hutchinsn Cancer Research Center MacMillan Cancer Supprt phagealcancer/othertreatments.aspx MacNair, T. Oesphageal Cancer. hagus.shtml May Clinic MedicineNet.cm factrs_fr_esphageal_cancer Medscape Reference Memrial Slan-Kettering Cancer Center Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] August 2017 Page 17