What is Esophageal Cancer?

Esophageal cancer is one of the common malignant tumors of the digestive tract, ranking as the 7th most common malignancy worldwide. There are approximately 320,000 new cases of esophageal cancer globally each year, with more than half occurring in China. Its mortality rate ranks 4th among all cancer deaths. The incidence and mortality rates of esophageal cancer show significant geographical clustering and familial predisposition. The male-to-female incidence ratio is approximately 2:1.

Overview of Esophageal Cancer in Indonesia
Esophageal cancer is the fifth most common cancer among Indonesian males, with approximately 4,200 new cases in 2022, accounting for 5.1% of all male cancer cases (Source: GLOBOCAN 2022). Because early symptoms (such as dysphagia and chest pain) are easily overlooked, over 60% of patients are diagnosed at an intermediate or advanced stage (III-IV), resulting in a 5-year survival rate of only 15%-20%, significantly lower than other digestive tract tumors like gastric cancer (35%).

In Indonesia, the main risk factors for esophageal cancer include: a diet high in salted and preserved foods (e.g., "ikan asin" in North Sumatra) and betel quid chewing (common in Kalimantan and Papua regions), both of which are closely associated with Esophageal Squamous Cell Carcinoma (accounts for 70% of cases). Additionally, HPV infection (in about 10% of cases) and reliance on cheap preserved foods among low-income groups are also significant contributing factors.

Diagnosis faces severe challenges: primary care often misdiagnoses early symptoms as gastroesophageal reflux disease (GERD), and only 25% of secondary and tertiary hospitals are equipped with high-definition endoscopy. Rural areas still rely on barium swallow radiography, which has a sensitivity of less than 50%. Distribution of pathological types shows Squamous Cell Carcinoma accounts for 70% (mainly associated with betel quid, smoking), while Adenocarcinoma accounts for 25% (associated with obesity, GERD).

Current major challenges include: lack of a national screening program leading to low early diagnosis rates; 70% of specialized medical resources concentrated in Java; and high treatment costs (out-of-pocket expenses for surgery can exceed 50%).

Future priorities include: promoting low-cost endoscopic screening for high-risk groups (e.g., betel quid chewers), construction of regional radiotherapy centers, and health insurance coverage policies for anticancer drugs.

(Data sources: WHO GLOBOCAN 2022, Indonesian National Cancer Center 2023 Report, Southeast Asian Journal of Oncology 2024 Esophageal Cancer Special Issue)

What are the Symptoms of Esophageal Cancer?

1. Early Symptoms: Often vary individually, with intermittent and non-specific discomfort during eating. This may manifest as an occasional sensation of food sticking or choking, or discomfort and fullness behind the breastbone.

2. Intermediate Symptoms: Difficulty swallowing (dysphagia), hiccups, or even vomiting frothy mucus, possibly accompanied by a heavy sensation in the chest or back. Patients may only be able to consume thin porridge, broth, or noodles, but not rice or meat.

3. Late Symptoms: Significant chest or back pain, difficulty swallowing liquids, frequent vomiting of food or mucus, with or without enlarged supraclavicular lymph nodes. If the tumor involves the recurrent laryngeal nerve or enlarged lymph nodes compress the nerve, symptoms like hoarseness and choking on drinking water may occur.

What are the Conventional Diagnostic Methods for Esophageal Cancer?

1. Barium Swallow Radiography (Esophagogram).

2. Computed Tomography (CT) Scan of the chest and abdomen.

3. Esophagogastroduodenoscopy (EGD) and Endoscopic Ultrasound (EUS).

4. PET/CT Scan.

How is Esophageal Cancer Treated?

The goals of treatment are to improve local control rates, survival rates, and preserve organ function and structure. For esophageal cancer treatment decisions, the tumor stage is the primary consideration.

Curative surgical resection and curative radiotherapy are the main treatment modalities for esophageal cancer. Mid-thoracic and lower-thoracic esophageal cancers are often suitable for surgical resection. In contrast, cervical and upper-thoracic esophageal cancers, due to their higher location (often at the level of the aortic arch or above the carina), present greater challenges for complete surgical removal. Radiotherapy often yields good results for these, and can be the primary choice as curative radiotherapy or combined chemoradiation.

For patients with advanced clinical stages where cure is not possible, palliative chemoradiation can be chosen as a means to alleviate symptoms and prolong survival.

When is Radiotherapy Suitable for Esophageal Cancer?

1. Curative radiotherapy for cervical and upper-thoracic esophageal cancers.

2. For operable esophageal cancer in patients who are medically inoperable due to conditions like heart disease, hypertension, etc., or who decline surgery.

3. For locally advanced disease without lymph node metastasis, preoperative radiotherapy may be used to increase the surgical resection rate.

4. For advanced esophageal cancer with lymph node metastasis, curative radiotherapy or concurrent chemoradiation is indicated.

5. Postoperative radiotherapy: Used when there is residual disease post-surgery or involved mediastinal lymph nodes.