Silent killer – oesophageal cancer

‘I don’thave time to baby sit attention seekers, how can an adult be refusing to swallow but complaining of hunger at the same time!’ the gentleman angrily muttered to himself as he cut the telephone line.  I would like to say I don’t like poking my nose in other people’s business but that would be a blatant lie because as a medical doctor that is all I do all day. A good history is key to solving a medical mystery so we tend to ask some pretty intimate questions during consultations.

Secondly in 15 minutes I was about to go on live television with this supposedly angry man. We were on opposing sides of a debate and I honestly didn’twant to be embarrassed by his bad mood. 

Thirdly by virtue of us being in the same space I had unintentionally been audience to the exchange he was having with the person on the other end of the line and it sounded like they were speaking about a relative who was in a peripheral town with a serious health problem and they needed to come to the city for further medical attention. The doctor in me couldn’tlet it go.

So I took my chances, quickly introducing myself as a doctor and enquired what the matter was. The worst that could happen would be that he would bite my head off but my question seemed to startle him, calming him down as he verified if I was addressing him. It was only the two of us at that point, as we waited to be called into the studio so clearly the question was addressed to him.

He cleared his throat and started explaining to me that his mother had been having swallowing problems for some time now. The problem had started a few months back at his wedding here in the city that had coincided with a funeral of a close relative in the village. She had been in the group of relatives that had thought to postpone the wedding, as the person who had died was an important elder in the family. The gentleman quickly added that these relatives had no insight into the costs or logistical nightmare of weddings nowadays considering the flowers for the wedding had been imported from Mauritius as an example. His mother swore something would go wrong if the elder was not properly buried and the responsibility would fall on her. However, the couple bulldozed their way and the wedding happened, as did the burial but without his mother. After the wedding she quickly headed to the village to pay her respects. During the hustle bustle of the wedding they had noted she was not eating much and even took to rejecting the piping hot tea from her daughter in law, which had initially won her over claiming her throat hurt when swallowing. They attributed this to her displeasure with regard to the wedding/ funeral saga. After a month of her visit in the village they started hearing reports that she stopped eating nshima as she couldn’t swallow solids. His sister requested money for jelly and soups from the newly opened Shoprite in the neighbouring small town. The couple thought these were attention-seeking tactics. The problem persisted and she was taken to a local private hospital where x-rays and scans were done and she was diagnosed with depression as the cause of her anorexia. Nothing was seen.

At this point in his narrative I interrupted him and asked if she had a tube with a camera called an endoscope done. He couldn’tconfirm but she was being taken to a very expensive facility in the vicinity that served rich farmers so it must have been a good facility.

Anyway, he continued narrating that the phone call he had just received was to urge him to go and pick up his mother from the village as she started forcing herself to vomit.

At that point we were called into the studio for the debate and I urged him to bring her to the city where facilities and specialists were more readily available.

Fast-forward a couple of months later, I met the gentleman along the corridors of the cancer center. His mother actually had advanced oesophageal cancer, had received palliative radiotherapy and was receiving chemotherapy. She was coping well.

He felt so guilty that he thought she had been on hunger strike for what seemed like silly reasons now. Of course he was curious to know what causes these cancers and as her son was he at risk? She was now incurable and he wondered if he had acted sooner her life would have been saved.

I explained to him that unfortunately no standardized screening tests are available for cancer of the food pipe and even in the best-resourced environments diagnosis can be delayed. However, clinician scientists even in Zambia are working hard to solve this problem. A screening test must always have overwhelming benefit, sensitivity and specificity compared to the risk of it being done. Sensitivity means its able to see something is wrong, whilst specificity is the correlation that what is wrong is what you are looking for rather than one of many options.

The oesophagus being a pipe like internal organ historically has been visualised with invasive methods such as gastroscopy. This is a camera on a tube navigated through the mouth down the throat and windpipe to the stomach. Most people find this uncomfortable and would only subject themselves to this if something is seriously wrong.

A game changer innovation that is cheap and quick to assess the upper digestive track less invasively and simply is a device called a Cytosponge developed in Cambridge. It is a mesh ball that is packaged in a regular sized capsule tagged to a string that a patient swallows. Once in the stomach its gelatin cover dissolves to expose the mesh ball. The ball is pulled back up through the food pipe collecting millions of cells, which are then assessed for abnormalities under the microscope. 

I reverted to encouraging the gentleman not to beat himself on this situation and reminded him of Jeremiah 17:10 as God knows the intentions of our hearts. He had overall been a good son to his mother. Knowing the poor survival rates and the end of life seen in such patients I said a quick prayer and went my way.

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