What to tell the patient with oesophageal cancer

1 When they first present with dysphagia and no investigations

You should express a concern that something nasty may be the cause of their problems.

Minimum investigations required before proceeding with any treatment includes oesophagoscopy and biopsy, and CT scan.

2 Patient presents with a known diagnosis of oesophageal cancer

All new referral patients with known oesophageal cancer have a CT scan booked, if they haven't had one, so that you can see it in out patients with the patient.

After assessing these patients, you have three options 

• Further investigations eg repeat endoscopy, bone scan etc You should explain to the patients that these additional tests are necessary so that you can better evaluate their tumour.
• Explaining that the tumour is removable - go to section 3
• Explaining that the tumour is unremovable - go to section 4

3 Telling the patient with potentially resectable cancer, they have oesophageal cancer and what needs to be done.

This needs to be conducted in a none rushed manner, preferably with the patients immediate relatives present. 

Obviously the patient needs to be told they have a growth or tumour, at which point they usually say you mean cancer.

You need to tell them there a number of treatment options which include:

• Doing nothing
• chemotherapy or radiotherapy
• Stenting
• Surgery

It should be explained that the only treatment that has any chance of a cure is surgery, as the other treatment options shrink the tumour or stretch it to allow them to eat and drink, but they don't remove it.

You need to tell them that oesophageal cancer is particularly nasty cancer and that even with apparently successful surgical removal the average patient lives only 18 months, but obviously that is only average and some live a lot longer and some less as the average includes all patients.

If you think the patient will benefit from pre operative (Neo-adjuvent) chemotherapy then you should explain to them that trials have shown that patient with your type of cancer do better long term if they have chemotherapy before the operation. You should put their mind at rest immediately and tell them that the chemotherapy that will be given doesn't make your hair fall out or make you fell very sick, as this is always on their mind.

The operation is a very big one that involves a very big cut all the way around the left side of the chest and into the abdomen. Obviously this will be painful so we will give you pain killers but you will experience some discomfort.

The risks of the operation need to be discussed with the patient and their relatives. Quoting a hospital mortality of between 5 and 10 % is usual. It is explained that this figure covers all causes of death during their hospital stay.

It should be explained that all their tests and scans have shown that you can remove their tumour, however in a few patients the scans haven't picked up where the tumour has spread to. In this case it may not be possible tom remove it.

The dreaded morbidity and subsequent mortality is anastomotic leak. We do not specifically warn the patient so of this unless we think that it is particularly high, as we feel that it is included in the overall 5 to 10% mortality.

Obviously the patient will be quite anxious by this point. You need to tell them, unless they have complete dysphagia, that there is no rush to perform their operation, and they will be called in the next few weeks.

4 Telling the patient they have un-resectable cancer

This needs to be conducted in a none rushed manner, preferably with the patients immediate relatives present. 

Obviously the patient needs to be told they have a growth or tumour, at which point they usually say you mean cancer.

You need to tell them that unfortunately surgery is not an option for them as the tumour has already spread too much / far. However their are a number of treatment options which include:

• Doing nothing - Sometimes the patients are remarkably asymptomatic, and in these this remains an option, however they should be warned that the tumour continues to grow and they will experience symptoms ion the future.
• Chemotherapy or radiotherapy - It should be explained that these can shrink the tumour down but don't offer a cure, however it should be explained that every patient and tumour is different and how much the tumour shrinks and for how long highly variable and not predictable.
• Stenting - This should be offered to all patients with symptomatic dysphagia and an un-resectable tumour if it is appropriate to do so.

Obviously combinations of the above are commonly used.