Palliative treatments of carcinoma of the oesophagus and stomach

Tumours of the oesophagus and gastric cardia

Dysphagia is the predominant symptom for most patients with tumours of the oesophagus, oesophagogastric junction, or gastric cardia. The progressive nature of malignant dysphagia is usually apparent. Initial difficulties in swallowing solid food may cause bolus obstruction and odynophagia. Solid food intake gradually reduces and, without treatment, patients may finally be unable to swallow saliva. Severe obstruction of the oesophagus may lead to aspiration pneumonia. Less than 5% of patients with oesophageal cancer develop an aero-digestive fistula, but this is generally associated with locally advanced disease and a very poor prognosis. Oesophageal tumours may also present with vomiting, haematemesis, or gastro-oesophageal reflux. Many patients present with other symptoms of advanced disease including fatigue, anorexia, abdominal pain (caused by ascites or liver metastases), or constipation. Rapid weight loss frequently occurs because of cancer cachexia exacerbated by poor oral intake. Hoarseness caused by tumour infiltration of the recurrent laryngeal nerves may result from advanced local disease or mediastinal recurrence after oesophagectomy.

Tumours of the gastric body and antrum

Gastric cancer commonly has an insidious presentation, and some patients have few symptoms. Slow blood loss may result in symptoms of anaemia. Haematemesis may be the first symptom. Vague upper gastrointestinal problems, such as epigastric discomfort, early satiety, and gastro-oesophageal reflux, are common. Tumours of the distal stomach may cause outlet obstruction and patients describe epigastric fullness, reflux, and nausea, finally leading to effortless and copious vomiting. The presence of an epigastric mass, supraclavicular lymphadenopathy, jaundice, ascites, or pleural effusions all reflect advanced disease. Less commonly, bony pain and symptoms of increased intracranial pressure are seen related to metastatic spread. Symptoms of oesophageal and gastric cancer are listed in Box 9.1 .

Patient selection and multidisciplinary teams

In the UK it is mandated that treatment decisions for patients with cancer are made within the context of an upper gastrointestinal multidisciplinary team meeting. Guidelines for the constitution and processes for upper gastrointestinal multidisciplinary teams are used by national health services and the process is peer reviewed to maintain standards. Teams consist of specialist nurses, gastroenterologists, oncologists, pathologists, radiologists, administrators, palliative medicine experts, and surgeons. Additional members may include cytologists, dieticians, endoscopists, and researchers from clinical trials units. The aim of the team meeting is to comprehensively review available information for each new patient and make optimal treatment recommendations. Information about the cell type, disease stage, comorbidity, and patient choice is considered. Although team working has been widely implemented across the UK and is mandatory, it may not be routine in other international centres. In the United States, a ‘multidisciplinary cancer case conference’ is required for American College of Surgeons Commission on Cancer accreditation. Expert opinion: Evidence from several studies has been combined in a systematic review showing that multidisciplinary meetings frequently make changes to diagnostic and treatment decisions. There is some evidence suggesting improved outcomes associated with discussion at a multidisciplinary meeting.

At first diagnosis, it is recommended that all patients are discussed at the multidisciplinary meeting, regardless of initial treatment intent. However, there is uncertainty whether upper gastrointestinal multidisciplinary teams should routinely discuss patients who develop disease recurrence following radical treatment. If this becomes mandatory in the UK the workload of teams could increase. Although optimising outcomes for patients with recurrence (especially after surgical resection) is very important, how they are best managed requires further consideration. Team working and teamwork training will continue to develop over the next decade; professionals may require specific skills and infrastructure to support these processes because high-quality information to inform clinical decisions is paramount to the process.

After establishing a diagnosis (see Chapter 3 ), new patients require careful assessment to decide whether treatment should be directed towards attempting a cure, or if palliation of symptoms is more appropriate. Careful patient selection has been shown to significantly influence results. Principal factors to consider are the type and stage of the tumour, physical and psychological well-being of the patient, and knowledge of patient preferences. Decisions should be considered in the knowledge of treatment outcomes, including impact on patients’ health-related quality of life and expected functional recovery. Disease stage, age, and performance status influence outcomes and survival, although the effect of age may be largely due to increased comorbidity in older patients. Another recognised predictor of mortality is the length of the oesophageal tumour, mainly because this increases the likelihood of nodal involvement. All these factors need to be taken into consideration when planning treatment. Figs. 9.1 and 9.2 illustrate pathways that can be used to select patients for palliative treatment.

Staging investigations

Accurate tumour staging plays a crucial part in any therapeutic protocol, enabling patients to be assigned appropriately to treatments with either curative or palliative intent. Clear evidence of haematogenous tumour spread or irresectability directs patients to palliative treatment. Palliative resection or bypass surgery to ameliorate bleeding or obstruction may be indicated for some patients with gastric cancer, even in the presence of haematogenous tumour spread. The decision to proceed with palliative surgery requires careful consideration as patients may rapidly deteriorate in the postoperative period. Chapter 3 describes details of staging protocols for patients with oesophageal and gastric cancer.

Patient preferences and information provision

Information about the diagnosis and prognosis of oesophageal and gastric cancer should be offered to all patients and it is essential that a clinical nurse specialist is involved in this process whenever possible. The volume and type of information required will vary between individuals, although evidence from studies of patients’ information needs performed in other disease sites generally show that patients wish to have as much information as possible and prefer the information to be provided by a health professional, as well as in other forms such as a booklet or video. To gain informed consent for treatment (or best supportive care), it is important to provide sufficient information to allow patients to be able to understand the benefits and risks of each treatment option, including no treatment, and to inform them of the likely short- and long-term outcomes. In the UK, this requires discussion of risk that is specific to the individual patient’s circumstances, such as their comorbidity or staging results, and exploration of the individual’s own information needs. Surveys of patients’ information needs show that information about impact of treatments on health-related quality of life is considered important to many patients during treatment decision-making. Many oesophagogastric centres supplement information given by clinicians and nurse specialists with written information sheets. While these are helpful, systematic analysis of information sheets provided for oesophageal cancer shows that they are often inconsistent and incomplete. Ensuring that consultations provide high-quality information in a way that is understood is important and in the UK it is recommended that all specialist cancer teams undergo training in advanced communication skills. There are also methods emerging to develop ‘core information sets’, which are the minimal baseline pieces of information that should be provided for patients in a particular clinical situation. Items within these ‘information sets’ may be selected through a rigorous method, incorporating views of patients and clinicians. Such information sets will be effectively patient centred. One has been developed for oesophageal cancer surgery. All clinicians will be faced with patients who demand every small chance of cure, despite its risks, and others who wish to receive minimal, dignified intervention. Communicating outcomes, providing adequate information, and listening to patients’ views is necessary so that patients and their family have access to as much information and support as required.

Palliative treatments for cancer of the oesophagus and gastric cardia

The provision of rapid relief of dysphagia for patients with advanced oesophageal and proximal gastric malignancies is the initial priority of palliative treatment for patients who are symptomatic, preferably with minimal intervention. A variety of approaches are available. These include insertion of self-expanding metal stents (SEMSs), endoscopic treatment with brachytherapy, chemical and thermal ablation, external beam radiotherapy (EBRT), and palliative chemotherapy. Treatments may be used individually or in combination. Palliative surgery is not indicated for oesophageal cancer due to the associated major complications and detrimental impact on patients’ quality of life. Patients do not have sufficient time to recover from the operation before they experience symptoms of metastatic disease. Non-surgical endoscopic interventions have the biggest role to play in palliation of malignant dysphagia and these are summarised in a recent Cochrane review which includes 51 trials.

The individual studies examining endoscopic methods of relieving luminal obstruction are considered in section 1, ‘Endoscopic methods for relieving luminal obstruction’, next and the other sections concentrate on treatments for palliation of other common problems in oesophageal or oesophagogastric junctional cancer. Medical oncological and radiation treatments are detailed in Chapter 8.

Endoscopic treatments

A tissue diagnosis is desirable prior to treatment of a malignant stricture and wherever possible should be undertaken as a planned procedure with informed consent. Endoscopic methods for relieving luminal obstruction include placement of stents, ablative techniques, and brachytherapy. Many modalities are complementary and no one method or combination is greatly superior to the rest in terms of relief of dysphagia.

Historically, dilatation and rigid plastic tubes were advocated for the palliation of malignant dysphagia. Because of the short-lived benefits of dilatation alone and the associated risks of perforation, its use nowadays is reduced to that of a preliminary measure before definitive management of dysphagia. Plastic tubes are also no longer used due to the risks of perforation and need for re-intervention. Minimal gentle oesophageal dilatation may be performed to allow insertion of a SEMS or to place a brachytherapy bougie. Guidelines on the use of dilatation in clinical practice recommend careful preparation, polyvinyl wire-guided bougies, or hydrostatic balloons. Strictures with severe narrowing and angulation are best negotiated under X-ray screening.

Endoscopic stenting