Esophageal cancer begins when the cancerous cells invade the inner layer of the esophagus wall and begins to multiply, eventually creating a tumor.
As the tumor grows, it can reach deep tissues, muscles of the esophagus, and the surrounding organs. There are two types of esophageal cancer, adenocarcinoma affecting the lower part of the esophagus and squamous cell carcinoma affecting the upper and middle part of the esophagus.
Esophageal cancer is aggressive and many people don’t notice symptoms until after the cancer has spread. It is the 10th most common cancer and the 6th most common cause of cancer mortality worldwide.
Signs and Symptoms of Esophageal Cancer
Initially, there may be no symptoms because the esophagus stretches as the tumor grows until it starts blocking food. Most symptoms are noticeable in the advanced stage and may include:
- dysphagia or difficulty swallowing
- painful in the throat or back radiating behind the breastbone or between the shoulder blades
- hoarseness
- indigestion and heartburn
- frequent choking while eating
- chest pain, burning, or pressure behind the breastbone
- vomiting or coughing of blood
- a lump under the skin
- sudden weight loss
- frequent hiccups
- black stool from esophageal bleeding
- Fatigue or bone pain
Causes of Esophageal Cancer
There is no known exact cause of esophageal cancer, but it is believed to be related to abnormal growth and mutations of cells. The following increases the chances of developing one.
- Tobacco use. Smoking damages the DNA that triggers abnormal cell changes.
- Alcohol abuse. Alcohol inhibits the body’s ability to absorb nutrients and vitamins. The body breaks down alcohol into acetaldehyde which damages the DNA cells.
- Obesity. This is associated with the increased prevalence of GERD in obese individuals.
- Chronic acid reflux. Gastric contents and acid from the stomach back up into the esophagus causing damage to the inner lining.
- Barrett’s esophagus. This condition affects the lower part of the esophagus with changes in the cells over time due to stomach acid.
- Human papillomavirus (HPV). HPV is a common virus that causes tissue changes in the mouth, vocal cords, extremities, and genitals. It is believed that HPV is involved in the pathogenesis of esophageal malignancy and is associated with poor response to oncological treatment.
- Occupational exposure to certain chemicals. Exposure to chemicals like dry cleaning solvents over a long period may cause damage to the inner lining of the esophagus.
- Other disorders. Rare disorders like tylosis in which there is an excess growth in the skin and achalasia which is a muscle disorder of the lower esophagus making it hard to swallow are both linked with esophageal cancer.
Risk Factors for Esophageal Cancer
Esophageal cancer affects 4 out of 100,000 people in the U.S. The following are the risk factor for esophageal cancer:
- People who are 45 years old and up have increased risk.
- Men are likely to develop esophageal cancer three times more than women.
- Black and Asian populations usually have squamous cell esophageal cancer.
- American or white populations are more likely to have adenocarcinoma esophageal cancer.
- Obesity and unhealthy diet.
- Individuals diagnosed with gastroesophageal reflux disease (GERD).
- Individuals with rare disorders such as Barrett’s esophagus and achalasia.
- Family history or people who previously had cancer of the neck or head.
Complications of Esophageal Cancer
Esophageal cancer can be debilitating if it’s already spread. The following are the complications of esophageal cancer:
- Difficulty or pain eating. Even after surgery, some patients may experience difficulty swallowing and significantly lose weight.
- Dumping syndrome. When the esophagus cannot do its job properly, the stomach will take its place and may not be able to hold food for digestion causing it to pass quickly.
- Anemia. This is a common diagnosis with esophageal cancer, which may be due to swallowing difficulties, nutritional deficit, and sudden weight loss. Patients may also experience chronic blood loss leading to iron deficiency anemia.
- Weight loss. Half of the patients with esophageal cancer experience sudden unexplained weight loss due to eating difficulties, swallowing problems, and decreased appetite.
- Cachexia. It usually occurs in advanced and metastatic cancers which involve the complex intertwining of dysphagia and odynophagia from esophageal obstruction caused by a tumor.
- Aspiration pneumonia. Patients with locally advanced cancer like esophageal, neck, and head have a high risk of developing aspiration pneumonia from chemotherapy or radiotherapy.
- Tracheoesophageal fistula. It is an abnormal connection between the trachea and esophagus that usually happens due to gastric acid erosion from the esophagus causing strictures or from surgery like esophagectomy.
- Metastases. Cancer cells can spread to different parts of the body such as lymph nodes, lungs, liver, adrenal glands, and bones. The prognosis of patients with distant metastasis is very poor esophageal cancer.
Diagnosis of Esophageal Cancer
The following test and procedure may be used to diagnose esophageal cancer:
- Patient history. A history of the patient’s health habits and past illnesses should be the focus of the assessment.
- Physical examination. Checking for general signs of the disease such as lumps or anything unusual using palpation and checking the patient’s ability to swallow for difficulties.
- Imaging. These tests will help identify the exact location, metastasis, or stage of the disease.
- Barium swallow study. During this study, the patient will swallow a liquid with barium and undergo x-rays. The barium will coat the lining of the esophagus to visualize changes to the tissue on x-ray.
- Computed tomography (CT) scan. Taking a series of detailed pictures taken from different angles to view the tissues more clearly.
- Esophageal endoscopic ultrasound. An endoscope will be inserted into the mouth to deliver high-energy sound waves to the internal organs forming an image of the tumor size and extent of tissue involvement.
- Esophagogastroduodenoscopy (EGD). A flexible tube with a video lens will pass down the throat into the esophagus to look for areas of irritation.
- Positron emission tomography (PET) scan. This technology can be used to determine the areas of involvement using a radioactive dye to highlight body parts while scanning.
- Biopsy. It is the collection of tissue samples suspicious of cancer cells to view microscopically. This is usually done with endoscopy for visualization.
- Grading. This describes the abnormal cancer cells’ growth and how quickly it is likely to spread.
- Grade 1. Cancer cells may look like normal cells.
- Grade 2. Cancer cells look abnormal; they grow and spread.
- Grade 3. Cancer cells look more abnormal and spread more quickly.
- Staging. This will determine the advancement of cancer.
- Stage 0. Abnormal cells are found in the lining of the esophagus.
- Stage I. Cancer cells are found in the layer of cells that line the esophagus.
- Stage II. Cancer cells reach the muscle layer or outer wall of the esophagus and may involve the lymph nodes.
- Stage III. Cancer cells reach the deeper muscle and connective tissue wall, it may reach into surrounding organs.
- Stage IV. Cancer cells have spread to other organs and lymph nodes far from the esophagus.
Treatment for Esophageal Cancer
Patients with esophageal cancer have a greater chance of survival if the illness is caught and managed early. The treatment of esophageal cancer depends on the cancer stage, grade, and overall health of the patient. These include:
- Chemotherapeutic treatment. This involves the use of drugs or procedures to kill cancer cells. It can be done before surgery or in combination with other therapy.
- Chemotherapy. These are drugs that stop the growth of cancer cells by killing or disrupting reproduction. It is given depending on the type and stage of the cancer being treated.
- Radiation therapy. This treatment uses high-energy radiation to kill cancer cells or contain them. This may be in the form of external or internal radiation depending on the type and stage of cancer.
- Endoscopic laser therapy. This treatment relieves symptoms of dysphagia or blockage in the esophagus.
- Photodynamic therapy (PDT). It targets cancer cells by using photosensitizers with a special laser light creating a chemical reaction to kill cancer.
- Targeted therapy. This treatment causes less harm to normal cells with the use of drugs or substances to attack and identify specific cancer cells.
- o Immunotherapy. This approach uses the patient’s immune system with some substances that are used to boost, restore, or direct the body’s natural defense.
- Electrocoagulation. It uses electric current to destroy cancer cells.
- Cryotherapy. This treatment freezes cancer cells to shrink the tumor.
- Radiofrequency ablation. It uses a device to target cancer cells with radiofrequency energy for the treatment of early-stage cancer.
- Surgery. These approaches are usually done for small tumors in the early stage.
- Endoscopic submucosal dissection (ESD). This is used for very early-stage esophageal cancer.
- Endoscopic mucosal resection (EMR). Used for small, early-stage, or high-grade dysplasia of the esophagus. An endoscope is inserted through a small incision with a tool attached to remove the tissue.
- Esophagectomy. A portion of the affected esophagus is removed and the stomach will be pulled up and anastomosed to the remaining esophagus. This is done for early-stage esophageal cancer.
Prevention of Esophageal Cancer
Reducing the modifiable risk factors associated with esophageal cancer may include the following steps:
- Avoid smoking, smokeless tobacco, and second-hand smoke.
- Limit drinking alcoholic beverages.
- Maintain a healthy weight.
- Eat foods with lots of fruits and vegetables.
- Avoid working around certain chemicals or solvents.
- For individuals with a high risk of acquiring HPV infection, the HPV vaccine is advised.
- Regular or annual EGD screening for individuals with GERD or Barrett’s esophagus.
Nursing Diagnosis for Esophageal Cancer
Nursing Care Plan for Esophageal Cancer
Risk for Altered Oral Mucous Membranes
Nursing Diagnosis: Risk for Altered Oral Mucous Membranes related to side effects of some chemotherapeutic agents and radiation secondary to esophageal cancer
Desired Outcomes:
- The patient will display intact mucous membranes, which are pink, moist, and free of inflammation/ulcerations.
- The patient will demonstrate techniques to maintain the integrity of the oral mucosa.
Esophageal Cancer Nursing Interventions
Assess and monitor the patient’s oral hygiene and dental health daily. This helps to identify the need for preventative care before the start of chemotherapy or radiation and offers baseline information on current oral hygiene for comparison in the future.
Promote the use of hard candies, mints, and artificial saliva as appropriate. This encourages secretions and provides moisture to keep mucous membranes intact, especially when there is dehydration and decreased saliva production.
Give instructions on dietary adjustments, such as to stay away from hot or spicy foods and acidic drinks; recommend the use of a straw; and consume soft or blended foods, popsicles, and ice cream as tolerated. Intake of nutrients and fluids may be hampered by severe stomatitis, which could result in less saliva or dehydration. Dietary changes could make it more comfortable and easier to swallow food.
Encourage the patient to drink at least 2 liters of water per day, unless contraindaicated. A healthy amount of hydration keeps mucous membranes from drying out and cracking by keeping them wet.
Talk about the restrictions on drinking and smoking. This may lead to more mucous membrane dryness and discomfort.
Before beginning chemotherapy or head or neck radiation, have the patient consult a dentist. The risk of infection is decreased by preventive and repair procedures prior to therapy.
Encourage people to refrain from using glycerin, lemon, or commercial mouthwash. Before meals, rinsing may enhance the patient’s sense of taste and soothe their membranes.
Nursing Care Plan for Esophageal Cancer
Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to consequences of chemotherapy as evidenced by the loss of patient’s body mass secondary to esophageal cancer
Desired Outcome: The patient will demonstrate stable or progressive weight gain toward the goal with normalization of laboratory values and be free of signs of malnutrition.
Esophageal Cancer Nursing Interventions
Observe the patient’s daily dietary intake and ask them to keep a food diary if necessary. Determines nutritional deficits and strengths.
Determine how much weight has recently been lost by measuring the patient’s height, weight, and tricep skinfold thickness. Weigh frequently or as directed. The patient’s main reserve of stored energy runs out if these measurements don’t meet the minimum requirements.
Hematest stools and gastric secretions. Antimetabolites used in some treatments prevent the GI tract’s epithelial cells from renewing, which can result in alterations ranging from minor erythema to severe ulceration and bleeding.
Encourage the patient to consume a diet high in calories and nutrients and to drink enough water. Promote frequent or smaller meals dispersed throughout the day and the use of supplements. Additionally metabolic tissue requirements rise to eliminate waste products. Maintaining sufficient protein and calorie intake might benefit from supplements.
Make the dining experience pleasant and encourage the patient to eat with friends and family. Increases enjoyment of eating, which can increase the patient’s intake.
Determine which patient is experiencing anticipatory nausea and vomiting, and take the necessary action. Pre-chemotherapy psychogenic nausea and vomiting typically do not react to antiemetic medications. On the day of treatment, a change in the patient’s routine or the treatment environment may be beneficial.
Enlist the aid of a nutritionist or nutritional support group. They can outline a customized diet to fulfil the needs of each individual and lessen issues with protein, calorie, and micronutrient deficits.
Nursing Care Plan for Esophageal Cancer
Nursing Diagnosis: Fear related to esophageal cancer diagnosis of the patient as evidenced by feelings of helplessness, hopelessness, inadequacy
Desired Outcome: The patient will demonstrate the use of effective coping mechanisms and active participation in the treatment regimen.
Esophageal Cancer Nursing Interventions
Determine the patient’s and their significant other/s present state of grieving, including its intensity. The degree of grief and coping mechanisms determine which therapy should be used.
Watch out for indications of despair and denial. On a scale of 1 to 10, determine whether suicidal thoughts are present and evaluate their likelihood. Patients may engage in denial as a form of defense and express the hope that the diagnosis is unreliable. The patient may retreat and think that suicide is an option due to guilt feelings, spiritual distress, physical symptoms, or a lack of treatment.
Keep in touch with the patient frequently. As necessary, speak to or touch the patient appropriately. This assures the patient that they are not alone or rejected; they are shown respect and acceptance, which promotes trust.
When immunosuppression or a radiation implant requires isolation, be cognizant of the patient’s effects. Use isolation masks and garments as little as possible. When there is insufficient stimulation, sensory deprivation may occur, which can make people feel more anxious, scared, and alienated.
Help the patient and their family identify and define their anxieties so they may start to come up with coping mechanisms. During various stages of treatment and after diagnosis, coping mechanisms are frequently emphasized. Support and counseling are frequently required for people to be able to detect
Give precise, consistent information on the diagnosis and outlook. Don’t argue about how the patient sees the situation. This can lessen anxiety and help patients make judgments and decisions based on facts.
Nursing Care Plan for Esophageal Cancer
Situational Low Self-Esteem
Nursing Diagnosis: Situational Low Self-Esteem related to the threat of death secondary to esophageal cancer as evidenced of low mood, decreased level of self-care or hygiene, and verbal report of low self-esteem
Desired Outcomes: The patient will begin to develop coping mechanisms to deal effectively with problems.
Esophageal Cancer Nursing Interventions
Encourage the discussion of worries about the impact of cancer and its treatments on the roles of parent, housewife, minimum wage earner, etc. This may aid in reducing issues that hinder treatment acceptance or speed up the disease’s development.
Recognize any challenges the patient may be going through. Inform people that getting counseling is a common and crucial step in the adaptation process. This demonstrates that the patient’s feelings are real and gives them the go-ahead to take whatever actions are required to cope.
Analyze the resources for support that patients and SO have access to and utilize. Helps aid in making plans for care before, during, and after discharge from the hospital.
During the course of the patient’s diagnosis and therapy, offer the patient and the family emotional support. Many patients require additional care during this time, even if other individuals are able to cope with the consequences of cancer or the adverse effects of treatment.
If the patient is okay with it, use touch throughout interactions while keeping eye contact. In order to lessen the patient’s emotions of uncertainty and self-doubt, it is crucial to affirm their originality and acceptance.
As necessary, recommend seeking professional counseling. If the patient’s and the family support networks are degrading, it could be necessary to re-establish and maintain a favorable psychosocial structure.
Discuss how the patient’s personal life is affected by the diagnosis and therapy with the patient and their family. This helps in outlining issues so that problem-solving can start.
Nursing Care Plan for Esophageal Cancer
Risk for Fluid Volume Deficit
Nursing Diagnosis: Risk for Fluid Volume Deficit related to impaired oral intake of fluids secondary to esophageal cancer
Desired Outcome: The patient will maintain adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor, prompt capillary refill, and individually adequate urinary output.
Esophageal Cancer Nursing Interventions
Observe the vital signs. Analyze the capillary refill and peripheral pulses. Examine the mucous membranes’ wetness and the skin’s turgor. Be aware of reports of thirst. This reflects the proper amount of circulation and indirect measures of the level and condition of dehydration.
Monitor laboratory investigations (CBC, electrolytes, serum albumin). Tests reveal the degree of hydration and any accompanying deficiencies.
Encourage individuals to increase their daily hydration intake to 3000 mL as tolerated or appropriate for them. Hydration helps individuals taking chemotherapeutic agents maintain their hydration needs and lowers their likelihood of adverse side effects such as hemorrhagic cystitis.
Cut back on venipunctures Encourage the patient to think about getting a central venous catheter. A central venous catheter reduces the risk of infection and bleeding brought on by frequent venous punctures.
Apply pressure to the puncture sites while avoiding trauma. Avoiding trauma lowers the likelihood of bleeding and hematoma formation.
Give IV fluids as needed. This is given to increase overall hydration, dilute antineoplastic medications, and lessen side effects (nausea and vomiting, or nephrotoxicity).
Monitor input and output strictly, as well as the urine specific gravity. Continued dehydration and the requirement for more fluid replacement are suggested by a negative fluid balance, declining renal output, and increasing urine concentration.
Keep an eye out for signs of bleeding, such as mucous membrane seepage or petechiae at puncture sites. Early detection of issues enables quick action (which may be caused by cancer or treatments).
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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