Abramson Cancer Center

There are risk factors that can increase the chance of developing cancer. Having a risk factor, or even several, does not mean that someone will get cancer. There are different kinds of risk factors.

Some risk factors for cancer, like age and family history, cannot be prevented. Patients who feel they are at risk may benefit from consulting with a risk assessment specialist within Penn Medicine’s GI genetics program.

Esophageal Cancer Risk Factors

Researchers believe chronic irritation of the esophagus may affect esophageal tissue and put some people at higher risk for developing esophageal cancer.

Some other risk factors include:

• Alcohol use
• Tobacco use
• Barrett’s esophagus
• Gastroesophageal reflux disease (GERD)
• Eating a diet low in fruits and vegetables
• Obesity
• African Americans (greater risk for developing squamous cell esophageal cancer)
• Caucasians (greater risk for developing adenocarcinoma)
• Overall, men are about three times more likely than women to develop esophageal cancer

Barrett’s esophagus is a condition in which the lining of the esophagus is damaged by stomach acid. Barrett’s esophagus is the body’s way of repairing the damage and this may increase the risk for developing esophageal cancer.

People diagnosed with Barrett's should be monitored for precancerous cells in the lining of the esophagus. If precancerous cells are found, they can be treated endoscopically to help prevent cancer.

Esophageal Cancer Prevention

The risk of esophageal cancer may be lowered by making several lifestyle changes:

• Limiting or eliminating alcohol use: Moderate or no consumption of alcohol can decrease the risk of developing cancer.
• Eliminating tobacco use: Smoking or chewing tobacco can increase the risk of developing cancer. Patients can get help to stop smoking through Penn Medicine’s Lung Center or through a smoking cessation research program at the Abramson Cancer Center.
• Eating a diet rich in fruits and vegetables: This includes fruits and vegetables that are green and yellow, and cruciferous vegetables such as cabbage, broccoli and cauliflower.
• Maintaining a healthy weight: Research has shown that obesity is a risk factor for developing esophageal cancer. A physician can help patients learn strategies to lose weight.

Esophageal Cancer Risk Assessment

Penn Medicine offers programs for patients who want to determine their risk of developing gastrointestinal cancer through the Penn GI genetics group.

This program offers knowledge about the presence of genetic risk factors for cancer and provides patients with important, sometimes life-saving options.

back to top

There are two main types of esophageal cancer and they are named for how the cancer cells look under a microscope. Both types begin in the cells in the inner lining of the esophagus, and are diagnosed, treated and managed in similar ways.

• Squamous cell
• Adenocarcinoma

Adenocarcinoma of the esophagus: Adenocarcinoma is usually found in the lower part of the esophagus, near the stomach. In the United States, adenocarcinoma is the most common type of esophageal cancer.
Squamous cell carcinoma of the esophagus: Squamous cell carcinoma is usually found in the upper part of the esophagus. This type is becoming less common among Americans, but around the world it is the most common type of esophageal cancer.

back to top

The symptoms for esophageal cancer may include:

• Dysphagia, problems swallowing or feeling like food gets stuck.
• Pain when swallowing.
• Pain in the chest or back.
• Losing weight without trying.
• Heartburn.
• A hoarse voice or cough that doesn’t go away in two weeks.

An early diagnosis can improve outcomes for esophageal cancer treatment. Patients with these symptoms should consult their physician.

back to top

After esophageal cancer is first diagnosed, a series of tests are used to investigate the extent of the cancer and to see whether it has spread to other parts of the body from where it started. Staging is a way of recording the size and growth of a cancer, and determining the plan for treatment.

• Stage 0. Abnormal cells are found only in the inner layer of the esophagus.

• Stage I. The cancer has grown through the inner layer into the submucosa.
• Stage II. One of the following:
  • Cancer has grown into submucosa and has spread to lymph nodes.
  • Cancer has invaded the muscles. Cancer cells are found in lymph nodes.
  • Cancer has grown through outer layer of esophagus.
• Stage III. One of the following:
  • Cancer has grown through outer layer of esophagus and has spread to lymph nodes.
  • Cancer has invaded nearby structures. Cancer cells may have spread to lymph nodes.
• Stage IV. The cancer has spread (metastasized) from where it started to other organs, such as the liver, bones or lungs.

back to top

After being diagnosed with esophageal cancer, patients at the Abramson Cancer Center may be evaluated through the Gastrointestinal Cancer Evaluation Center (GICEC). The center provides patients with expert support and evaluation to discuss treatment options and individualized treatment plans.

Patients with esophageal cancer are treated by a multidisciplinary team of cancer specialists who see more patients with gastrointestinal (GI) cancers in one year than many doctors see in their careers.

Penn Medicine’s GI cancer program has physicians nationally recognized for their expertise in the diagnosis and treatment of cancer.

Penn’s GI cancer treatment team includes:

• Nationally recognized medical experts with years of experience in diagnosing and treating GI cancer.
• Nurses with advanced training and experience.
• Oncology Navigation Specialists to help patients navigate the health system.
• Registered dietitians to provide nutrition counseling.
• Cancer counselors to provide individual or family counseling for issues many cancer patients face.
• Rehabilitation therapists who specialize in the diagnosis and treatment of physical effects from cancer and its treatment.
• An esophageal cancer support group for patients and their loved ones.

Patients at Penn Medicine can benefit from participating in clinical trials that take place at Penn. Patients interested in learning more about clinical trials should speak with someone on their treatment team.

Oncology Navigation Specialists

Every step of cancer treatment – from cancer diagnosis, to surgery and treatment to forming a survivorship plan – comes with different needs and issues that should be addressed.

Oncology Navigation Specialists at the Abramson Cancer Center are available to make a patient’s experience as seamless as possible. As experts in navigating complex health care situations, patient support specialists serve as a consistent point of contact and a reliable source for advice, support and direction for patients and families. They can help in a variety of ways including; provide emotional support, identify resources, and ensure access to information, support services, educational programs and community resources.

Learn more about Patient Navigation specialists at the Abramson Cancer Center.

back to top

Currently, there are no standard screening recommendations for the general public like mammograms for breast cancer and colonoscopy for colon cancer.

However, surveillance is very important for people diagnosed with Barrett’s esophagus to ensure their disease does not progress to cancer. Patients with Barrett’s esophagus may undergo esophageal biopsies through an endoscopic procedure. A biopsy can detect if cancerous cells are present.

back to top

Penn Medicine’s multidisciplinary cancer team includes nationally recognized gastroenterologists, pathologists and radiologists who are experts at finding and diagnosing cancer.

If cancer is suspected, one or more of these diagnostic tests may be ordered:

• Imaging tests. Pictures of the inside of the body can help find out whether a suspicious area might be cancerous, to learn how far cancer may have spread, and to help determine if treatment is working.
• Barium swallow. Patients swallow a liquid containing barium and a series of X-rays are taken. The barium coats the lining of the esophagus, stomach and intestines, so abnormalities are easier to see on the X-ray. If there is an abnormality detected, an endoscopic biopsy can help make the diagnosis of cancer.
• Endoscopy. An endoscope, a thin instrument with a camera and biopsy channel, is used to examine the esophagus. Tissue samples may be taken to check for cancerous cells.
• Endoscopic ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. This procedure is often done at the same time as the upper endoscopy. The endoscopic ultrasound can show enlarged lymph nodes, which may indicate a tumor or advanced disease. Needle biopsies may be obtained to help in staging and diagnosis.
• Computed tomography (CT) scan. A CT scan creates a 3-D X-ray of the inside of the body. A computer combines the images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan is used to see if the cancer has spread to the liver and to detect a carcinoid tumor in lymph nodes behind the abdomen. Sometimes, a contrast medium (dye) is used to provide better detail.
• Positron emission tomography (PET) scan. A PET scan creates pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into the patient and cancer cells absorb the radioactive substance. A scanner detects this substance to produce images.
• Bronchoscopy. A bronchoscopy uses an endoscope to look into the windpipe (trachea) and lung structures to examine if cancer is present in some patients.
• Thoracoscopy and laparoscopy. These procedures allow a physician to see lymph nodes and other organs to see if cancer has spread. Biopsies may be taken of the organ tissue if there is a question concerning suitability for surgery.
• Biopsy. A sample of the suspicious area is removed and viewed under a microscope.  A biopsy, such as fine-needle aspiration, is the only way to tell if cancer is truly present.

back to top

After cancer is first diagnosed, a series of tests are used to investigate the extent of the cancer and to see whether it has spread to other parts of the body from where it started. Staging is a way of recording the size and growth of a cancer, and determining the plan for treatment.

• Stage 0. Abnormal cells are found only in the inner layer of tissue lining the esophagus; also called carcinoma in situ.

• Stage I. The cancer has grown through the inner layer of tissue to the next layer in the wall of the esophagus.
• Stage II. One of the following, divided into IIA and IIB.
  • IIA: Cancer has spread to the layer of esophageal muscle or outer wall of the esophagus.
  • IIB: Cancer may have spread to any of the first three layers of the esophagus and to the nearby lymph nodes.
• Stage III. Cancer has spread to the outer wall of the esophagus and may have spread to tissues or lymph nodes near the esophagus.
• Stage IV. One of the following, divided into IVA and IVB.
  • IVA: Cancer has spread to nearby or distant lymph nodes.
  • IVB: Cancer has spread to distant lymph nodes and/or organs in other parts of the body.

A Penn Medicine cancer physician can answer any questions about the stage of cancer and what it might mean regarding prognosis and treatment.

back to top

Penn Medicine offers patients one of the largest gastrointestinal surgery programs in the United States with nationally recognized cancer specialists. Penn's GI surgery program has a record of high-quality patient care and long-term survival, offering better outcomes for patients having surgery.

Nationally, surgery is the most common treatment for esophageal cancer, though endoscopic therapies for early tumors are rapidly increasing in application. For limited stage esophageal cancer, surgery may be the only treatment needed.

Esophagectomy is the most common form of surgery for patients with esophageal cancer. In this procedure,the part of the esophagus affected by cancer is removed. The healthy part of the esophagus is then connected to the stomach. Lymph nodes near the esophagus are also removed and examined for cancer. If the esophagus is blocked by a tumor, an expandable stent, or tube, may be placed prior to surgery to help keep the esophagus open to improve nutritional status, or after surgery for palliation.

back to top

Radiation oncologists at Penn Medicine are recognized for techniques that target radiation precisely to the disease site while sparing nearby tissue. Penn is one of the only health care systems in the country to use proton therapy for cancer treatment.

Proton therapy at Penn Medicine is now being used to treat upper gastrointestinal cancers and recurrent tumors in the digestive tract. Penn Medicine is one of the only facilities in the country treating gastrointestinal cancers in this way.

Radiation therapy uses high-energy radiation to kill cancer cells. A radiation therapy schedule usually consists of a specific number of treatments given over an extended period of time. In many cases, radiation therapy is capable of killing all of the cancer cells.

Radiation oncologists at Penn Medicine use both internal and external forms of radiation therapy to treat cancer.

3D Conformal Radiation Therapy

The imaging technology used by radiation oncologists at Penn Medicine helps shape the radiation treatment beam to the shape of the tumor. Known as conformal radiation therapy, this technology gives doctors more control when treating tumors.

In conformal radiation, a special computer uses CT imaging scans to create 3-D maps of the cancer’s location in the body. The system permits the delivery of radiation from several directions and the beams can then be shaped, or conformed, to match the shape of the cancer. Conformal radiation therapy limits radiation exposure to nearby healthy tissue as well as the tissue in the beam's path.

Intensity-Modulated Radiation Treatment (IMRT)

As national leaders in radiation therapy, radiation oncologists at Penn Medicine are experts in the use of the latest therapies, including intensity-modulated radiation therapy (IMRT), to treat cancer.

This advanced type of radiotherapy uses a computer-controlled device, called a linear accelerator, to deliver precise doses of radiation to tumors or specific areas within the tumors. Radiation therapy, including IMRT, stops cancer cells from dividing and growing, thus slowing or stopping tumor growth. In many cases, radiation therapy is capable of killing all of the cancer cells.

Using 4-D computed tomography (CT) images along with computerized dose calculations, IMRT allows for the radiation dose to conform more precisely to the shape of the tumor by controlling, or modulating, the intensity of the radiation beam while tracking any movement of the tumor.  The therapy allows higher radiation doses to be delivered to regions within the tumor while minimizing the dose to the surrounding area.

Volumetric-Modulated Arc Therapy (VMAT)

Volumetric modulated arc therapy (VMAT) is a type of specialized intensity modulated radiation therapy. VMAT delivers radiation by rotating the linear accelerator through one or more arcs while radiation is continuously delivered.

VMAT allows Penn radiation oncologists to treat complex cancers while minimizing exposure to surrounding healthy tissue. VMAT shortens radiation delivery time, and offers patient more comfort because it does not require patients to lie completely still for long periods of time.

Penn radiation oncologists use RapidArc™ radiotherapy technology to treat hard to reach tumors.

Proton Therapy

Penn Medicine is the only health care facility in the country that is using proton therapy to treat recurrent gastrointestinal tumors in clinical trials.

Penn Medicine's Roberts Proton Therapy Center is the largest and most advanced facility in the world for this precise form of cancer radiation. Patients have access to one of the most sophisticated weapons against cancer, seamlessly integrated with the full range of oncology services available at Penn Medicine. Proton therapy is external beam radiotherapy in which protons are directed at a tumor.

The radiation dose that is given through protons is very precise, and limits the exposure of normal tissues. This allows the radiation dose delivered to the tumor to be increased beyond conventional radiation. The result is a better chance for curing cancer with fewer harmful side effects.

Proton therapy, like all forms of radiation therapy, works by aiming the energized particles, in this case protons, onto the target tumor. These particles damage the DNA of cells, ultimately causing their death. Unlike X-rays, protons can be manipulated to release most of their energy only when they reach their target. With more energy reaching the cancerous cells, more damage is administered by each burst of radiation.

back to top

Penn Medicine specializes in a team approach to treatment with interdisciplinary care and innovative approaches that use chemotherapy to target tumors prior to surgery. Penn medical oncologists are experienced with providing chemotherapy to patients with esophageal cancer.

Chemotherapy uses drugs to kill cancer cells. It is delivered in the bloodstream intravenously or through a pill, and targets cancer cells throughout the body.

Depending on the stage of the tumor, chemotherapy in combination with radiation therapy, or chemoradiation therapy, may be used as a primary treatment or in combination with surgery.

back to top

Endoscopy is performed using an endoscope, a long, narrow tube equipped with a light, video camera and other instruments, to examine the upper digestive system.

Endoscopic mucosal resection (EMR)

Endoscopic mucosal resection is performed using an endoscope. During endoscopic mucosal resection, the endoscope is passed down the throat to reach the abnormality in the esophagus. Instruments attached to the endoscope are used to remove the tumor.

Radiofrequency ablation

Radiofrequency ablation is an endoscopic procedure involving targeted thermal energy to kill the cells lining in the esophagus as a treatment for Barrett’s esophagus, a precancerous condition. The radio waves kill the altered cells and prevent them from becoming cancer.

Endoscopic Stent Placement

Endoscopic stents may be placed for palliative relief of dysphagia.

Nutrition Support for Esophageal Cancer

Many people with esophageal cancer find it hard to eat because they have trouble swallowing. The esophagus can be narrowed by the tumor or as a side effect of treatment. Some patients may receive nutrition intravenously or through a feeding tube passed through the nose or mouth into the stomach until they are able to eat on their own. Endoscopic therapies including dilation and stent placement may improve the swallowing function and nutritional status.

A specialized oncology dietitian is available to help with swallowing difficulty, weight loss, specialized diets and nutritional assessment. Speech and swallowing therapists are also available to help with symptoms.

back to top

Today, more and more people are surviving cancer. Clinical trials benefit patients with breakthrough therapies and treatments. These new advances in cancer treatment are occurring every day at Penn Medicine, giving patients hope that even greater discoveries lie ahead. Through clinical trials:

• Diagnosing cancer has become more precise.
• Radiation and surgical techniques have advanced.
• Medications are more successful.
• Combinations of medical, surgical and radiation therapy are improving treatment effectiveness and enhancing outcomes.
• Strategies to address the late effects of cancer and its treatment are improving quality of life.

Penn Medicine is the only health care facility in the country that is using proton therapy to treat recurrent gastrointestinal tumors in clinical trials. Also, radiation oncologists at Penn Medicine will soon use proton therapy to treat gastrointestinal cancers in the upper digestive tract.

back to top

In addition to standard treatments and clinical trials, patients at Penn Medicine may wish to add additional therapies and treatments such as massage therapy, acupuncture and art therapy. These therapies do not have curative intent, and are designed to complement standard treatments – not take their place.

Integrative Medicine and Wellness Programs

At Penn Medicine, integrative medicine and wellness services can supplement traditional cancer treatments such as chemotherapy, surgery and radiation therapy. While conventional medicine plays a critical role in eradicating cancer, integrative medicine and wellness programs offer patients and their families ways to enhance the quality of their lives, minimize or reduce the side effects of cancer and cancer treatment, and promote healing and recovery.

Cancer specialists at Penn Medicine are knowledgeable and supportive of complementary cancer treatments. The cancer team works with patients and families to integrate these supportive programs into the overall care plan, while ensuring the safety and health of patients.

The Abramson Cancer Center’s range of integrative supportive services is designed to help patients cope with the cancer experience and improve their overall sense of well-being. Services include:

• Acupuncture
• Diet and nutrition
• Mindfulness-based stress reduction therapy
• Reiki therapy
• Yoga
• Exercise and rehabilitation

The Joan Karnell Cancer Center at Pennsylvania Hospital offers a variety of supportive care programs for patients and families, from diagnosis through survivorship. These programs are available at no cost to the patients treated at Pennsylvania Hospital, and some are open to patients treated elsewhere. These services include social work counseling, nutrition counseling, psychological counseling and spiritual counseling.

The Cancer Appetite and Rehabilitation Clinic focuses on patients with loss of appetite and weight.

The Supportive Care Clinic helps to manage cancer related symptoms. Integrative support programs include:

• Music therapy
• Art therapy
• Shiatsu massage
• Mindfulness meditation

Support groups and educational programs are available at Pennsylvania Hospital throughout the year.

Palliative Care

Palliative care provides medical and non-medical interventions to ease the symptoms of cancer and its treatment. Palliative care includes physical, emotional and spiritual care that can enhance the quality of life for cancer patients.

Palliative care can be used to complement traditional cancer therapies, or can be used to improve quality of life when curative therapies are no longer an option.

Palliative care is an approach to patient care that can be integrated with curative therapies at any point from diagnosis to survivorship or end-of-life care.

Palliative care services include palliative chemotherapy, radiation therapy and surgery as well as psychological counseling, art therapy and support groups for patients and families. The goals of palliative care are to enhance the quality of life for cancer patients and their families, and provide emotional and spiritual support to enhance personal growth.

Palliative care services are offered at Pennsylvania Hospital, and at the Hospital of the University of Pennsylvania.  

Penn Home Care and Hospice Services

Penn Home Care and Hospice Services offer a full range of home health care needs by partnering three top-level home health care services under one roof:

• Penn Wissahickon Hospice
• Penn Care at Home
• Penn Home Infusion Therapy

Penn Home Care and Hospice Services offer an array of specialized therapies and medications for patients with cancer and cancer-related conditions.

Oncology Navigation Specialists

Every step of cancer treatment; from a cancer diagnosis, to surgery and treatment to forming a survivorship plan; comes with different needs and issues that should be addressed.

Oncology Navigation Specialists at the Abramson Cancer Center are available to make a patient’s experience as seamless as possible. As experts in navigating complex health care situations, patient support specialists serve as a consistent point of contact and a reliable source for advice, support and direction for patients and families. They can help in a variety of ways including; provide emotional support, identify resources, and ensure access to information, support services, educational programs and community resources.

Learn more about Patient Navigation specialists at the Abramson Cancer Center.

back to top

At the end of treatment, esophageal cancer patients should schedule a survivorship visit with their oncologist and nurse practitioner. At this time, patients are provided with a summary of the treatment received as well as a plan for follow-up care.

Penn cancer providers work one-on-one with esophageal cancer patients to develop their survivorship care plans. Since every cancer is unique, the plans are tailored to the patients. 

The survivorship care plan includes information on:

• Potential long-term or late side effects of cancer treatment, their symptoms and treatment.
• Recommendations for cancer screening for disease recurrence or a new cancer.
• Psychosocial effects, including concerns with relationships and sexuality.
• Planning follow-up visits.

Survivorship care plans encourages patients to review the information with their healthcare team and become active participants in their follow-up care.

Penn also offers esophageal cancer patients a number of support programs and groups to enhance their survivorship care plans.

Oncology Navigation Specialists

Every step of cancer treatment – from cancer diagnosis, to surgery and treatment to forming a survivorship plan – comes with different needs and issues that should be addressed.

Oncology Navigation Specialists at the Abramson Cancer Center are available to make a patient’s experience as seamless as possible. As experts in navigating complex health care situations, patient support specialists serve as a consistent point of contact and a reliable source for advice, support and direction for patients and families. They can help in a variety of ways including; provide emotional support, identify resources, and ensure access to information, support services, educational programs and community resources.

Learn more about patient navigation specialists at the Abramson Cancer Center.

back to top

Penn Medicine’s Living Well After Cancer™ Program is a nationally recognized program that focuses on issues facing cancer survivors. In 2007, the Abramson Cancer Center was designated a LIVESTRONG™ Survivorship Center of Excellence Network.  The Abramson Cancer Center is only one of eight LIVESTRONG centers in the United States, and is the only LIVESTRONG Survivorship Center of Excellence in the Philadelphia region. The program focuses on survivorship, a distinct phase of care.

Prescription for Living: The Cancer Survivorship Program at the Joan Karnell Cancer Center at Pennsylvania Hospital provides patients with a summary of important information about specific cancer diagnoses and treatments, as well as follow-up information and steps to take towards recovery, supportive care and education to help patients adjust to their lives as cancer survivors.

back to top

Penn offers cancer patients support programs and groups to enhance their survivorship care plans.

The Abramson Cancer Center hosts a wide range of materials and activities that provide education and support to address key areas of concern including survivorship for cancer patients and their loved ones.

Focus On: Gastrointestinal Cancers is a day-long conference that addresses issues for patients with esophageal cancer, as well as their loved ones.

The Joan Karnell Cancer Center at Pennsylvania Hospital also offers an esophageal cancer support group for patients and their loved ones. Facilitated by a registered dietitian and a social worker, this group offers education, guest speakers and emotional support.

back to top