By Corinna Wu

American Eyewitness

Nearly 45 years after her death from esophageal cancer, Dorothea Lange’s Great Depression photographs remain an inspiration

By Corinna Wu

The symptoms a person may experience typically depend on the cancer’s location in the esophagus. People with a tumor high up in the esophagus will often have pain and trouble swallowing. Tumors farther down will make the person feel like food is getting stuck and may cause regurgitation. Other symptoms of esophageal cancer include unexplained weight loss, anemia, and a hoarse voice or cough that doesn’t go away after a couple of weeks. Lange’s tumor was found in the mid-upper portion, which was probably why the first symptom she noticed was trouble swallowing.

An Array of Risk Factors
Esophageal cancer is divided into two main categories: squamous cell cancer and adenocarcinoma. Squamous cell cancer begins in the flat cells lining the esophagus and can develop anywhere along the length of the esophagus; adenocarcinoma originates in the cells that produce fluids like mucus and tends to affect the lower portion. Two decades ago, says surgeon Marco Patti, the director of the Center for Esophageal Diseases at the University of Chicago Medical Center, the majority of esophageal cancers were the squamous cell kind, which are linked to smoking and heavy alcohol use. Now, the majority are adenocarcinomas, which are linked to gastro-esophageal reflux disease. (Obesity increases the risk of gastroesophageal reflux disease.) Though it’s not clear which type of cancer Lange had, her tumor’s location and the fact that she was a chain smoker suggest she had the squamous cell kind.

Gastroesophageal reflux is a risk factor that affects a fifth of the U.S. population, according to statistics from the National Institutes of Health. The condition occurs when the sphincter at the bottom of the esophagus doesn’t close properly, and stomach acid washes up into the esophagus and causes irritation. Eventually, the acid causes the cells lining the esophagus to change from their normal flat shape into a columnar shape—a precancerous condition called Barrett’s esophagus. At that point, explains Maish, the cells in the esophagus have changed so much to protect themselves against the acid reflux that they now “look like intestinal cells.”

Today it’s known that a person with Barrett’s esophagus has about a 1 percent chance each year of developing cancer. By monitoring these high-risk patients, and treating them with modern techniques like radiofrequency ablation that kill the errant cells or endoscopic mucosal resection to remove them, esophageal cancers can be caught early, or even prevented.
 
Treatment Options
When Lange was diagnosed in 1964, treatment options for esophageal cancer were limited to surgery and radiation therapy. “In the ’60s, the mortality rate in the hospital for one of these operations was 20 to 25 percent,” says Patti, whereas nowadays, in specialized centers, the rate is less than 5 percent.

For esophageal cancer, surgery has traditionally been the primary treatment. The operation usually involves removal of the whole esophagus, which requires pulling the stomach “either to the apex of the right chest or sometimes all the way to the neck,” says Patti. Afterward, Maish says, most people are able to gradually begin eating their normal diet—except perhaps in smaller portions.

(photo: © The Dorothea Lange Collection, Oakland Museum of California, City of Oakland. Gift of Paul S. Taylor)