Gastrooesophageal Cancer

Gastrooesophageal cancer forms at the critical junction where the food pipe meets the stomach, presenting unique challenges that require specialized, multi-faceted treatment approaches.

Table of contents

• What is Gastrooesophageal Cancer?
• Types of Gastrooesophageal Junction Cancer
• Signs and Symptoms
• Risk Factors and Causes
• Diagnosis and Testing
• Treatment Options
• Nutrition and Eating Challenges
• Living with Gastrooesophageal Cancer

What is Gastrooesophageal Cancer?

Gastrooesophageal cancer, also known as gastroesophageal junction cancer (GEJ) or oesophago gastric junctional cancer, is cancer that develops at the point where the food pipe (esophagus) joins the stomach. This area is called the gastroesophageal junction^[3].

• Esophagus (food pipe)
• Stomach
• Gastroesophageal junction

Cancer occurs when abnormal cells start to divide and grow in an uncontrolled way. Over time, these cells can grow into surrounding tissues or organs, and may spread to other areas of the body^[3].

It can sometimes be difficult to tell the difference between stomach cancer, esophageal cancer, and gastrooesophageal junction cancer. However, research shows that gastrooesophageal junction cancers are a separate type of cancer. They can behave differently to cancers of the esophagus and stomach. The number of people who develop this type of cancer is going up^[3].

Gastrooesophageal cancers, including both gastric (stomach) cancer and gastroesophageal junction cancer, are aggressive diseases that are challenging to treat. Despite being relatively rare in the United States—accounting for a little more than 1% of all cancer cases diagnosed annually—these cancers are serious conditions. Gastric cancer sees nearly 30,000 new diagnoses each year in the US, while gastroesophageal junction cancer (commonly called esophageal cancer) makes up about 22,000 new cases annually^[4].

Types of Gastrooesophageal Junction Cancer

There are three types of gastrooesophageal junction cancer, depending on where the cancer is located^[3]:

Type 1: This type spreads down into the gastroesophageal junction from above. The cancer cells are found in the lower part of the esophagus and the gastroesophageal junction. The center of the cancer is between 1 and 5 centimeters above the junction^[3].

Type 2: This type develops at the actual gastroesophageal junction itself. The center of the cancer is between 1 centimeter above and 2 centimeters below the junction^[3].

Type 3: This type spreads up into the gastroesophageal junction from below. There are cancer cells in the top of the stomach and the gastroesophageal junction. The center of the cancer is between 2 and 5 centimeters below the junction^[3].

Signs and Symptoms

The symptoms of gastrooesophageal junction cancers are very similar to esophageal cancer symptoms. Early symptoms may go undetected until the disease is in advanced stages, making it harder to treat. Because symptoms are often subtle and nonspecific in nature, it is easy for some patients to mistake them for less serious conditions or ignore them altogether^[4].

The most common symptoms include^[3]:

• Difficulty swallowing (dysphagia)—this is the first symptom people may notice
• Unexplained weight loss
• Indigestion or heartburn that doesn’t go away
• Chest pain, pressure, or burning
• Vomiting or coughing up blood
• Hoarseness or chronic cough

Additional symptoms may include^[4]:

• Feeling bloated after eating
• Feeling full after eating small amounts of food
• Severe, persistent heartburn
• Severe indigestion that is always present
• Unexplained, persistent nausea
• Stomach pain
• Persistent vomiting
• Blood in the stool, which over time can lead to anemia (low red blood cell levels) and fatigue

Many other conditions cause these symptoms. Most of them are much more common than gastrooesophageal junction cancer. If you have any of these symptoms, it is important to see your doctor to get them checked^[3].

Risk Factors and Causes

The exact causes of gastrooesophageal cancers are not well understood, but it is believed that genetics, environment, and lifestyle may all be contributing factors^[4].

Different types of gastrooesophageal junction cancer have different risk factors^[3]:

Type 1 gastrooesophageal junction cancers are similar to esophageal cancers. Barrett’s esophagus increases the risk of type 1 cancer. This is a condition where the cells lining the esophagus have become abnormal. This can happen due to long-term acid indigestion (acid reflux)^[3].

Type 2 cancers are not as well understood compared to type 1 and 3. This is because the characteristics of type 2 cancer cells are somewhere between stomach and esophageal cancer cells^[3].

Type 3 gastrooesophageal junction cancers are similar to stomach cancers. They are linked to infection with Helicobacter pylori (H. pylori), a bacteria that lives in the mucus that lines the stomach^[3].

Additional risk factors include^[4]:

• Diet, such as high consumption of meat, very hot liquids, or salty and smoked foods
• Smoking and tobacco products
• Alcohol use
• Low physical activity
• Being obese
• Certain demographics, such as men and individuals over 55
• Other conditions such as chronic gastroesophageal reflux disease (GERD)—when acid from the stomach repeatedly leaks back into the esophagus

Diagnosis and Testing

Your doctor will arrange tests to find out the cause of your symptoms. The main test is called a gastroscopy, also known as an endoscopy or oesophago gastric duodenoscopy (OGD). This test looks at the inside of your esophagus, stomach, and first part of your small bowel (duodenum)^[3].

During the test, your doctor passes a long flexible tube (endoscope) into your esophagus. It has a tiny camera and light on the end. They then take samples of tissue (biopsies) of any abnormal-looking areas^[3].

If you are diagnosed with cancer of the gastroesophageal junction, you will have further tests to find out more. These tests include^[3]:

• Endoscopic ultrasound
• CT scan
• PET-CT scan
• Laparoscopy

The stage of a cancer tells you about its size and whether it has spread. It helps your doctor decide which treatment you need^[3].

Treatment Options

Treatment of gastrooesophageal cancer often requires multiple treatment methods working together, including chemotherapy, immunotherapy, radiation, and surgery. A multi-disciplinary team, including radiation oncology, surgical oncology, and medical oncology, is essential to maximize patient outcomes^[17].

The treatment you have depends on whether or not the cancer has spread^[11].

When the Cancer Hasn’t Spread

Your doctor will probably offer you surgery. They might suggest you have treatment before surgery. You might have chemotherapy before and after surgery (called perioperative chemotherapy) or chemoradiotherapy before surgery^[11].

Surgery for most gastrooesophageal junction cancers is a major operation. Your doctor will make sure you are fit enough to make a good recovery. You might have chemoradiotherapy instead if you aren’t well enough to have surgery^[11].

For very early stage cancer, you might have surgery on its own without other treatments, or if you aren’t well enough to have other treatments. To remove a very early gastrooesophageal junction cancer, you might have an operation called an endoscopic resection. Your doctor passes a long flexible tube (endoscope) into your esophagus and removes the cancer through special instruments^[11].

When the Cancer Has Spread

Treatment options include^[11]:

• Chemotherapy
• Chemoradiotherapy
• Targeted cancer drugs
• Immunotherapy
• Treatment to relieve symptoms, such as radiotherapy or a stent

Types of Surgery

The surgery you have depends on your type of gastrooesophageal junction cancer^[11]:

For Type 1 cancer: You usually have surgery to remove two thirds of your esophagus, the nearest lymph nodes, and possibly the top of the stomach. This is called an oesophagectomy or oesophago gastrectomy^[11].

For Type 2 and 3 cancers: You might have surgery to remove part of your esophagus, the top of your stomach, and surrounding lymph nodes (an oesophago gastrectomy). Or you might have surgery to remove your stomach, the lower end of your esophagus, and the surrounding lymph nodes. This is called an extended total gastrectomy^[11].

Because esophageal surgery is not common in many hospitals, it is critical that an esophageal surgeon specialist is consulted. The operation can last from 6 to 7 hours. Patients can expect to stay in the hospital between 7 and 10 days. Additional recovery at home can take from 4 to 6 weeks^[17].

Other Treatments

Current FDA-approved treatments include HER2-targeted therapy, immunotherapy, and chemotherapy. Novel therapeutic targets are under development, and future treatments will be personalized based on molecular profiling^[14].

Immunotherapy is being used to help prevent the disease from coming back after treatment. Researchers are working on treatments that will help people with gastrooesophageal cancer live longer^[15].

Nutrition and Eating Challenges

Gastrooesophageal cancer can cause problems with swallowing and make it hard to eat well. One of the most critical areas of care is nutrition. For symptomatic gastrooesophageal cancer, an oncology nutritionist is a critical part of the patient’s care team^[17].

It’s important to eat and drink enough calories and protein to maintain your weight and strength. There will be a dietitian in the team looking after you. They can help you cope with eating problems and suggest ways of dealing with diet difficulties^[19].

Making Eating Easier

If you find swallowing difficult, there are ways to help^[19]:

• Eat small amounts more often
• Eat soft, moist foods
• Eat slowly and chew your food well
• Take sips of a drink between mouthfuls
• Try to make the most of the times during the day that you feel able to eat

Soft Diet Suggestions

A soft diet can help you eat more comfortably. Try scrambled egg, soups, and mashed potato. You can also^[19]:

• Use sauces, cream, and gravies to moisten food and make it easier to swallow
• Soften meat and vegetables with long, slow cooking
• Finely chop meat and vegetables in a food processor before or after cooking
• Blend or process meat or vegetable casseroles or curries to make soups
• Make fruit smoothies or milkshakes in a blender
• Try tinned fruit and add custard or cream
• Have ice cream, yogurts, and mousse

Building Yourself Up

You can help to maintain your weight by adding calories to everyday foods^[19]:

• Have soft cereal for breakfast—add honey or sugar and cream or whole milk
• Make instant soups or gravies with milk instead of water
• Mix mashed potato with butter, grated cheese, or cream
• Make drinks like coffee or hot chocolate with all milk instead of water, preferably whole milk
• Drink liquid food supplements such as Complan and Meritene—sip them throughout the day

Feeding Tubes

You may need a feeding tube down your nose or put into your small bowel if you can’t eat and drink enough. Often, patients will require a temporary feeding tube for daily nourishment^[17]. You can go home with the feeding tube in place. Your team will teach you or your carer how to use the tube once you’re at home^[19].

Living with Gastrooesophageal Cancer

Living with gastrooesophageal cancer will mean changes in your lifestyle. You’ll need to find the quality of life that suits you best. For some people, treatment can remove or destroy the cancer (curative therapy). For other people with advanced incurable disease, the cancer might never go away (palliative therapy). Some people may get regular treatments with chemotherapy, radiation therapy, or other treatments to try and help keep the cancer in check^[20].

Gastrooesophageal cancer patients will need to make significant changes in diet and eating habits. You may find you need to eat small frequent meals permanently. Eating a diet rich in fruits and vegetables, staying at a healthy weight, getting regular physical activity, and avoiding or limiting alcohol are all linked with a lower risk of getting gastric cancer^[9].

Follow-Up Care

Even if you have completed treatment, your care team will still watch you closely. It’s very important to go to all your follow-up appointments. During these visits, your doctors will ask if you are having any problems and may do exams and lab tests or imaging tests to look for signs of cancer or treatment side effects^[20].

Many doctors recommend follow-up visits with a physical exam (which may include imaging tests, blood tests, and endoscopy) every 3 to 6 months for the first two years after treatment. This is often changed to visits every 6 to 12 months for the next 3 years, and then once a year after that^[20].

Support and Resources

Eating problems can be difficult to cope with. They can cause tension within relationships or families. Social events and eating out with friends can be much harder when you have a problem swallowing. Talking to your dietitian or a counsellor can help^[19].

Physical therapists and occupational therapists are often needed to assist the patient after surgery^[17].

Unfortunately, both gastric cancer and gastrooesophageal junction cancer are often diagnosed in the advanced stages when they are more challenging to treat. Even when diagnosed earlier when the cancer may be treatable with surgery, approximately one in four patients still experience their disease returning within one year, and one in four patients do not survive beyond two years. The five-year survival rate remains poor, with less than half of patients alive at five years^[4].