In geographic areas where there is a high risk of
esophageal cancer, analysis of cells obtained from the esophagus has been used effectively to detect early lesions. This has been demonstrated on a large scale in studies from China. Using abrasive balloon cytology techniques, 75% of the
cancers detected were early lesions, where the 5-year survival after resection was in the range of 90%. Endoscopic followup studies indicate that dysplastic changes in the esophageal mucosa are a common precursor to
malignancy. In many cases, the time course from dysplasia to
carcinoma in situ to early invasive
cancer may take place over many years, allowing a reasonable amount of time for screening. In low-incidence areas, such as the United States, most
esophageal cancers are related to the excessive use of tobacco and alcohol. These factors are too common and the incidence of the disease too low, however, to justify screening on this basis. There are smaller groups at higher risk where selective screening by endoscopy with cytology and biopsy is recommended, usually every 1 to 3 years. These include patients with longstanding
achalasia,
lye strictures, and
Plummer- Vinson syndrome. Patients with
cancers of the head and neck region and patients with
celiac disease may also be considered to be at increased risk.
Tylosis is a rare inherited disease with a very high risk of
esophageal cancer. There is an increased incidence of
adenocarcinoma of the esophagus with Barrett's epithelium, and once identified such patients should be kept under endoscopic surveillance. The finding of severe dysplasia in any of these groups would indicate a shorter screening interval. Most patients with symptoms referable to the esophagus are first tested by
barium esophagram. If negative, with persistent symptoms or if a suspicious lesion is identified, endoscopy with cytology and biopsy is recommended. Staging of the
cancer is based on the size of the
cancer both longitudinally and circumferentially and the presence of extraesophageal spread. At the present time, CT is the best noninvasive method for judging the extent of the
cancer. Performance and nutritional status are also determinants of prognosis and should be considered in planning treatment.