Oesophageal cancer: ‘People definitely rally around when they think you are going to pop your clogs’

Golfer Pádraig Harrington is taking no chances with his own health, having seen his father die of oesophageal cancer that was diagnosed too late to save him from a premature death at the age of 72.

For years, as patron of the Oesophageal Cancer Fund (OCF), the 52-year-old has been raising awareness about the importance of not ignoring possible warning signs, such as persistent reflux. Now he is taking his own advice. “I have never had reflux and I have just got a persistent cough and reflux for the first time,” the winner of three majors and former Ryder Cup captain tells The Irish Times. “I am taking further action and will continue to investigate what’s causing it.

“I am in no fear at all at the moment because it’s so early, and I know to be ahead of the game on this. But it is interesting – a lot of these things are in your genes, so I will be proactive.”

Due to his family history, Harrington has had a screening scope, “and I am perfectly fine”, but the latest symptoms have come on in recent weeks after having pneumonia. He kept thinking he was over it and went back playing on the senior professionals’ PGA Tour Champions in January. But, “in hindsight, I wish I took those weeks off, as I thought I was okay”.

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He recalls how his father, Paddy, who had played senior GAA football for Cork and was a keen golfer, was forever taking indigestion tablets, but thought nothing of it. “It is sad because he was fit and strong – besides his cancer. He kept himself very fit and active. He would be in his 90s now; he would probably be playing golf in his 90s.”

Harrington thinks fitter people may tend to overlook niggles, “as that is what they have always done. If they are into their sports, they are a little bit harder and get through knocks. The problem with all cancers, and particularly this one, is if you leave it too late... If you catch it early, your chances are great with oesophageal cancer, and it has advanced so much since my father passed away in 2005. It’s all about early detection.”

This is why Harrington uses his public profile to raise awareness of symptoms and to urge people to get checked if they have any worries.

Warning signs include:

• Difficulty swallowing
• Persistent acid indigestion, heartburn, reflux
• Persistent coughing and frequent hiccups
• Unexplained weight loss

One oesophageal cancer survivor, Seán O’Keeffe, has recounted how he heard the golfer talking on radio about the death of his father, identified with some of the symptoms and immediately made an appointment to see his GP. “If I hadn’t heard Pádraig that day I might not have done anything for six months, or even a year. I could have just put off the discomfort as indigestion. I was lucky that it was detected early,” he says in his survivor story on ocf.ie.

[ Early diagnosis credited for near-total survival from some cancers after five years ]

“That is why you do these things,” says Harrington, minutes after completing a photo shoot at his home in south Dublin to front publicity for OCF’s annual fundraiser Lollipop Day on February 23rd. OCF is using Lollipop Day to urge the Irish pharmaceutical sector to promote early detection by carrying bigger and better warnings on their antacid packaging and through their advertising, as they do in the US market for example.

Brendan Nagle, a financial regulator with the Central Bank, knows now how subtle symptoms of oesophageal cancer can be and how narrow a window you have to do something about it. The dawning of concern for him started with an episode of “choking very distressingly” on some chicken at home in Dundrum, Dublin, in November 2019.

Despite something similar happening again after Christmas that December, it was mid-January before “I toddled to my GP”, who urged him to get a camera scope exam done without delay. Nagle still let a couple of weeks lapse before making an appointment for January 31st, 2020. “I woke up and they told me there is something there, it’s serious. They knew what it was.”

He was referred to the St James’s Hospital team of consultant surgeon Prof John Reynolds, national lead for oesophageal and gastric cancer, whom he met five days later. He recalls thinking the turnaround time was so quick, “it was a bit disconcerting – impressive too though”.

After being diagnosed with a cancerous tumour located where the oesophagus connects to the stomach, Nagle started a very aggressive form of chemotherapy, named FLOT after the initials of the drugs used, on March 2nd, 2020. “You’re on that for fortnightly stints. It blows the hair out of your head, literally. The purpose is to shrink the tumour, so you can stop choking for one thing, but so they can do the operation.”

He also went into training with hospital physiotherapist Sarah Wade in preparation for the physical demands of surgery.

After the FLOT, his body was given a month to recover before undergoing surgery on June 16th, 2020, amid Covid-19 pandemic restrictions. Although a St James’s team was performing the operation, he was able to have it done in the Beacon Hospital, closer to his home. “I was very fit going into the surgery, but one of the pitfalls is pneumonia, and I was one of the 20 per cent who get that.”

He didn’t get out of the Beacon until July 19th, five weeks after the surgery. “When you get pneumonia it becomes very life-threatening.”

I feel very well. I have lost weight and I have lost muscle mass, but I am very light on my feet, which helps on a tennis court

—  Brendan Nagle, oesophageal cancer survivor

The next stage in treatment was “clean-up” chemotherapy. He was in a clinical trial to look at whether the best treatment should be chemotherapy on its own or chemotherapy and radiation, and he was in a control group for the former. However, Prof Reynolds and oncologist Prof Maeve Lowery differed in their opinions on the advisability of Nagle having the full post-surgery chemotherapy programme after his bout of pneumonia.

“It was, quite admirably in my view, left up to me,” says Nagle. “I went to the junior surgeon, Noel [Donlon], and said, ‘What would you do’? He suggested I try some of it at least – so instead of four fortnights, I did two fortnights, and then I could do no more. I think Reynolds and Lowery both got it right to leave it to me. I thought it was a good example of patient empowerment. They would have both got it wrong if either had forced it.”

He returned to work in May 2021, but in November 2022 ran into complications from the abdominal surgery. Adhesions, “almost invisible ivy that touches on to your bowel, turns it upside down and almost kills you”, had caused an obstruction. He needed additional surgery to clear that on January 4th, 2023. This meant “another big hiatus from work”, but he is very glad he had an income protection policy in place. “That helped with a lot of things that would have otherwise become very financially ugly.”

Nagle says his quality of life now “is really quite good”, but there is no denying that treatment for oesophageal cancer has a lifelong effect. He is coping with a much smaller digestive system, which means food is prone to move too quickly from the stomach into the small intestine. “It causes sugar spike and causes pain. Movement is almost mandatory for the rest of your days if you want to digest properly.”

He can still eat almost anything, but has to watch the balance and volume of what he consumes. “My personal experience is that fully sedentary work is quite dangerous to somebody in my position. You have to move a lot more during the day. In my case I play a lot of tennis. It gets movement going that otherwise may not happen.

“I feel very well. I have lost weight and I have lost muscle mass, but I am very light on my feet, which helps on a tennis court,” he says with a laugh. “But there is a loss of energy and a lot of napping needed.”

His employer has been very good to him, he says, and he is not sure full-time work in an open-plan office would ever be an option for him again. “Three cheers for remote [working]. I would still get fairly severe digestive problems up to five times a week.”

Nagle believes most oesophageal cancer survivors would change their work and lifestyle habits. “It’s big – and it’s fantastic to survive it. I can’t over-praise the level of care I got.”

While he didn’t have any psychological issues during his illness, it has changed his outlook on life. “I have a lot more trust in people than I used to have. You don’t get through this without relying hugely on other people’s help. So in a way I am a more philosophical person afterwards than before – a kind of happier person.

It has got to be something to do with Western lifestyles. It parallels the changes in diet, the rise in metabolic conditions such as diabetes, obesity of course, and reflux

—  Prof John Reynolds

“People definitely rally around when they think you are going to pop your clogs,” he jokingly observes. “You have more chance of doing that than living,” he adds, in reference to the five-year survival rate being just over 20 per cent for people with this form of cancer.

“It is a difficult cancer,” says Prof John Reynolds, with survival rates nothing like those for prostate or breast cancer. That’s partly because it has a different biology and partly because “it can be a little bit silent. When you first notice something is wrong, that you can’t swallow properly or are anaemic, it might be more advanced than you would like.”

However, for those who are diagnosed early enough to be assessed as potentially curable, the three-year survival rate here is closer to 60 per cent, having more than doubled since the late 1990s. “If say 400-450 patients are diagnosed with oesophageal cancer in Ireland every year, only about 150-170 can be treated with any prospect of curative intent,” he explains. Others can be helped with palliative care, and even chemotherapy and immunotherapy, “but a cure is almost never achieved in that context; occasionally you will see a near miracle”.

Untreatable cases would also include patients diagnosed at a very advanced age or having coexisting conditions.

Incidence of oesophageal cancer has grown about fourfold in the Western world over the last four decades. “It has got to be something to do with Western lifestyles. It parallels the changes in diet, the rise in metabolic conditions such as diabetes, obesity of course, and reflux,” says Reynolds. It is not known why it is so much more common among men than women, occurring in a ratio of about eight or nine to one.

Reflux is a potentially predisposing feature of this cancer because the repeated flow of stomach acid back into the oesophagus causes inflammation. If not properly controlled, that inflammation can lead to pre-cancer and cancer. But reflux is very common, stresses Prof Reynolds, with maybe up 20 per cent of people having it to some extent on a weekly basis. It is those who have reflux almost daily and whose situation it is not controlled by antacid who should definitely see a GP.

[ Oesophageal Cancer: ‘Early diagnosis gives you a real chance to get ready for what lies ahead’ ]

[ What to look out for: Symptoms of oesophageal cancer ]

Persistent reflux can trigger a change in the cells lining the lower oesophagus, causing a condition known as Barrett’s Oesophagus, which is associated with an increased risk of cancer. Anybody diagnosed with that condition goes on the national Barrett’s registry and is monitored through regular screening. This has made a huge difference in reassuring most patients, Prof Reynolds says, while leading to earlier diagnoses in the few whose condition does progress.

“Only about 5 per cent of patients with Barrett’s Oesophagus are unlucky enough to develop cancer, which should be picked up early enough.”

Unlike when he was starting out in this field 30 years ago, treatment of an early cancer “involves just surgery down the camera – a most minimally invasive procedure that can cure the cancer before it has had the chance to take proper root and become malignant, and all that potentially implies”.

He also highlights how the multidisciplinary team approach that operates across all cancers now is hugely beneficial to patients as they go through treatment and live beyond it. This is particularly important in oesophageal cancer, where treatment can be so debilitating and challenging.

Prof Reynolds praises the OCF’s contribution to the improvement of survival rates by raising awareness of symptoms and funding ongoing research through Lollipop Day. He also welcomes the launch last year of an all-Ireland research network, funded by €1 million from Breakthrough Cancer Research, to look at all aspects of oesophageal cancer prevention and treatment on this island.

For Carmel Doyle, who became chief executive of the OCF at the start of this year, the role brings together both the professional and the personal. Previously chief executive of the Jack and Jill Foundation, she knows first-hand the invaluable peer support the OCF community offers patients and carers. Her husband Gerry Martin, a taekwondo master, was treated for oesophageal cancer nearly 13 years ago and has recovered very well.

[ Winning the fight against cancer: ‘It’s just miraculous’ ]

Harrington says while he “swans in” at this time of year for the Lollipop Day campaign, it is the hard-working people behind the scenes at the OCF who are doing a great job. The information about symptoms has to be out there, he stresses, and we don’t need any stigma around getting things checked out. “I have had a few skin things removed, non-melanoma ones thankfully. I am quick enough now if I know somebody and see something: ‘just have that checked out’.”

Meanwhile, of golf, he says: “I love it still. I have gone through that phase of being burned out and rundown – I am back keen and excited. I have found a new lease of life.”

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