What is oesophageal cancer?
Cancer of the oesophagus, also known as oesophageal cancer, is an uncommon but serious type of cancer that affects the oesophagus (gullet).
The oesophagus is the medical name for the gullet, which is part of the digestive system. The oesophagus is the long tube that carries food from the throat to the stomach. The top part of the oesophagus lies behind the windpipe (trachea). The bottom part runs down through the chest between the spine and the heart.
Symptoms of oesophageal cancer include:
- difficulties swallowing (dysphagia)
- weight loss
- throat pain
- persistent cough
See your doctor if you have any of these symptoms. They don’t necessarily mean that you have oesophageal cancer, but they will need to be investigated.
Your doctor will take a detailed look at your medical history before carrying out a physical examination to check for any signs of abnormalities, such as a lump in your abdomen that may indicate a tumour.
If your doctor still suspects oesophageal cancer you will be referred for further tests. Read more information about how oesophageal cancer is diagnosed.
Types of oesophageal cancer
There are two main types of oesophageal cancer:
- Squamous cell carcinoma forms in the upper part of the oesophagus. It occurs when cells on the inside lining of the oesophagus multiply abnormally.
- Adenocarcinoma of the oesophagus forms in the lower part of the oesophagus. It occurs when cells inside the mucous glands that line the oesophagus multiply abnormally. The mucous glands produce a slimy substance to help food slide down the oesophagus more easily.
How common is oesophageal cancer?
Oesophageal cancer is uncommon, but it is not rare. It is the ninth most common type of cancer in the UK, with more than 8,000 new cases diagnosed each year.
Oesophageal cancer mainly affects people over the age of 55, with the average age at diagnosis being 72. The condition is more common in men than in women.
Smoking and drinking alcohol are two of the biggest risk factors for oesophageal cancer, particularly if both activities are combined. People who drink heavily but do not smoke are four times more likely to develop oesophageal cancer than non-drinkers, and people who smoke and do not drink alcohol are twice as likely to develop oesophageal cancer.
However, people who smoke and drink heavily (more than 30 units a week) are eight times more likely to develop oesophageal cancer than those who do not smoke or drink.
Treating oesophageal cancer
Oesophageal cancer does not usually cause any noticeable symptoms until the cancer has spread beyond the oesophagus and into nearby tissue. For this reason it can be more difficult to cure compared with other types of cancer.
On average, 30% of people with oesophageal cancer will live for one year after the diagnosis, and 8% will live for five years after the diagnosis. This increases when the cancer is diagnosed and treated at an early stage, and where a cure is possible. In such cases it is estimated that 34-42% of people will live for two years after the diagnosis, and some people may live much longer.
If a cure is not achievable, it is usually still possible to relieve symptoms and slow the spread of the cancer using a combination of radiotherapy, chemotherapy and surgery.
Read more information about how oesophageal cancer is treated.
Help and support
A diagnosis of cancer is a tough challenge for most people. There are a number of ways you can find support to help you cope, although not all of them work for everybody.
Read about living with oesophageal cancer for more information on getting help with:
- recovery and follow-up
- your relationships with others
- talking to other people who have oesophageal cancer
- money and financial support
- free prescriptions
- palliative care
Cancer of the oesophagus symptoms
When cancer of the oesophagus first develops it rarely causes any symptoms. This is because the tumour is very small. It is only when the cancer starts to become larger and more advanced that symptoms will start to develop.
Difficulty swallowing (dysphagia) is the most common symptom of oesophageal cancer. However, you will not usually experience any difficulty swallowing until the tumour has grown large enough to narrow your oesophagus to about half its normal width.
As the tumour narrows your oesophagus it becomes more difficult for food to pass down. When you swallow it can feel as if food is stuck in your gullet as the muscles of the oesophagus try to push it past the tumour.
You may find you have to chew your food more thoroughly, or you can only eat soft foods. If the tumour continues to grow even liquids may be difficult to swallow.
Other symptoms of oesophageal cancer include:
- unexplained weight loss (caused by a combination of difficulties swallowing and the cancer’s harmful effects on your body)
- pain when swallowing (odynophagia)
- throat pain and discomfort
- persistent indigestion (dyspepsia) that could also include chest pain
- persistent cough
- coughing blood
When to seek medical advice
You should contact your doctor if you experience difficulties swallowing for more than a week.
Dysphagia can have a wide range of causes, which means your symptoms are unlikely to be related to oesophageal cancer. However, a formal diagnosis of your symptoms is recommended.
Want to know more?
- Cancer Research UK: symptoms of oesophageal cancer
- Macmillan: symptoms of oesophageal cancer
Cancer of the oesophagus causes
Although the exact cause of oesophageal cancer is not known, certain factors are thought to increase the risk of it developing.
Cancer begins with an alteration to the structure of the deoxyribonucleic acid (DNA) found in all human cells. This is known as a genetic mutation. The DNA provides the cells with a basic set of instructions, such as when to grow and reproduce.
The mutation in the DNA changes these instructions so that cells carry on growing. This causes the cells to reproduce in an uncontrollable manner, producing a lump of tissue known as a tumour.
How cancer spreads
Most cancers grow and spread to other parts of the body via the lymphatic system. The lymphatic system is a series of glands (or nodes) located throughout your body in a similar way to your blood circulation system. The lymph glands produce many of the specialised cells needed by your immune system (the body's natural defence against disease and infection).
Left untreated, oesophageal cancer spreads through the outer lining of the oesophagus and into nearby organs such as the liver, lungs or stomach.
Exactly what causes oesophageal cancer to develop is uncertain. However, it appears that repeated and prolonged exposure of the lining of the oesophagus to toxic substances is a significant risk factor.
Known risk factors for oesophageal cancer are explained below.
Read more information about preventing oesophageal cancer.
Drinking too much alcohol increases your risk of developing a number of illnesses and conditions, including cancer of the oesophagus. Long-term heavy drinking causes irritation and inflammation in the lining of the oesophagus. If the cells in the lining of your gullet become inflamed, they are more likely to become malignant (cancerous).
Using any form of tobacco (including cigarettes, cigars, pipes and chewing tobacco) will increase your risk of developing cancer of the oesophagus.
When you smoke tobacco you always swallow some of the smoke, which contains many harmful toxins and chemicals. These substances irritate the cells that make up the lining of the oesophagus, which increases the likelihood that they will become malignant.
The longer you smoke, the greater your risk of developing oesophageal cancer.
Gastro-oesophageal reflux disease (GORD)
A valve known as a cardiac sphincter is located between your stomach and oesophagus. The valve usually only opens when food is ready to pass from your oesophagus into your stomach.
Sometimes the valve becomes weakened, or it relaxes at the wrong time. This condition is known as gastro-oesophageal reflux disease (GORD).
If you have GORD, stomach acid is able to travel up into your oesophagus. When this happens it causes heartburn, a form of indigestion that causes pain in the front of your chest.
However, it should be stressed that the risk of developing oesophageal cancer from GORD is very small, and most people with GORD will not go on to develop cancer.
If you have chronic acid reflux it can sometimes lead to you developing another condition called Barrett's oesophagus. Barrett's oesophagus causes new cells that are very similar to stomach cells to develop in the lower oesophagus. These abnormal cells are resistant to stomach acid but are more likely to become malignant in the future.
Approximately one person out of 10 who has chronic acid reflux goes on to develop Barrett's oesophagus. You are more at risk if you have had chronic acid reflux for a prolonged period of time. About one person in 100 with Barrett's oesophagus develops cancer of the oesophagus.
If you are severely overweight, your risk of developing cancer of the oesophagus is approximately double compared with people with a healthy weight for their height. This may be because obese people are more at risk of developing Barrett's oesophagus (see above).
A diet low in fruit and vegetables or lacking in vitamins A, C, B1 or zinc has been shown to increase the risk of cancer of the oesophagus. If you eat a healthy, balanced diet you will usually get enough vitamins and zinc in your diet naturally.
Cancer of the oesophagus is much more common in the Far East and Central Asia. It is thought that this may be partly due to the type of diet in these countries, which includes far fewer uncooked vegetables than the western diet. It may also be due to environmental factors.
It is rare for anyone under the age of 45 to develop cancer of the oesophagus. However, any symptoms should still be investigated.
Most people who develop the condition are between 55 and 70 years of age. Cancer of the oesophagus is also more common in men than in women. For example, in the UK in 2008, 8,173 people were diagnosed with cancer of the oesophagus and 5,461 were male.
Chemicals and pollutants
Long-term exposure to chemicals and pollutants may irritate your oesophagus, particularly if you inhale these substances. Chemicals and pollutants known to increase the risk of oesophageal cancer include:
- metal dust
- vehicle exhaust fumes
- lye (a chemical found in strong industrial and household cleaners)
- silica dust (which comes from materials such as sandstone, granite and slate)
If you have to work with these substances as part of your job, make sure you take all the necessary health and safety precautions. This should help to minimise your exposure to these potentially harmful substances.
Information and advice about health and safety at work can be found on the Health and Safety Executive website.
Want to know more?
- Cancer Research UK: risks and causes of oesophageal cancer
- Macmillan: causes of oesophageal cancer
Cancer of the oesophagus diagnosis
If your doctor suspects you have cancer of the oesophagus they will first take a detailed look at your medical history before carrying out a physical examination.
They will then arrange for you to go to hospital to see a specialist for further tests.
The specialist will look for any signs of abnormalities, such as a lump in your abdomen, which may indicate a tumour. Before testing for oesophageal cancer they will carry out a physical examination, and may check your general health with blood tests and a chest X-ray.
This is one of the first tests you will have to help confirm a diagnosis of cancer of the oesophagus.
Endoscopy is a medical procedure that allows doctors to see inside the body. During this procedure a thin, flexible instrument called an endoscope is passed through your mouth and down towards your stomach.
The endoscope has a light attached to the end and feeds back the images of your oesophagus to a monitor. This will allow your doctor to look for any signs of abnormal cells or tumours.
Before having an endoscopy you should avoid eating for several hours, as food can obstruct the view of the endoscope.
An endoscopy should not cause you any pain, although it may feel uncomfortable. Before the endoscopy takes place you will normally be given a local anaesthetic or sedative to help you relax and to help make the procedure less uncomfortable. The endoscopy itself will usually take about 15 minutes, although you should allow approximately two hours for your visit.
After an endoscopy you may notice that you have a sore throat, which will usually last for a few days. If your symptoms persist, see your doctor.
A barium swallow is a test that involves drinking a thick white liquid called barium. Once you have swallowed the barium you will undergo a series of X-rays.
The barium coats the lining of your oesophagus so that it shows up on the X-ray. These X-rays are able to show your doctor whether there is an obstruction in your oesophagus, which may be an indication of a tumour.
You may have to undergo this test if your cancer has already been diagnosed, as it will help your doctor to assess the size of your tumour.
A barium swallow usually takes about 15 minutes to perform. After the procedure you will be able to eat and drink as normal, although you may need to drink more water to help flush the barium out of your system.
If the initial tests confirm a diagnosis of oesophageal cancer, further tests may be needed to see where the cancer is and if it has spread. These tests may include:
- a computerised tomography (CT) scan
- an endoscopic ultrasound
- a laparoscopy to take a sample of cells (biopsy)
- a positron emission tomography (PET) scan
These are described in more detail below.
Computerised tomography (CT) scan
A CT scan takes a series of X-ray images of your body and uses a computer to put them together. This then creates a very detailed picture of the inside of your body.
This will help your doctor assess how advanced your cancer is. It allows them to see whether the cancerous cells have formed tumours in any other places within the body. A CT scan will also allow your doctors to work out which type of treatment will be most effective and appropriate for you.
Once cancer of the oesophagus has been diagnosed your doctor will need to assess how far the cancer has spread and how large the tumour has grown.
An endoscopic ultrasound will help your doctors assess how far your oesophageal cancer has progressed. It involves having a very small ultrasound probe passed into your oesophagus using an endoscope. This test produces sound waves that can penetrate the surrounding tissues.
These waves are then used to produce an image of your oesophagus so your doctor can see if the cancer has spread to the surrounding tissue.
A laparoscopy may be used to examine the area, depending on the location of the tumour. A sample of cells can be taken (biopsy) by using a special extracting instrument connected to the laparoscope.
A laparoscopy is carried out under general anaesthetic, so it will require a short stay in hospital.
The biopsy will be examined underneath a microscope in a laboratory and the results will show whether the cells are malignant (cancerous) or benign (non-cancerous). The results will normally take seven to 10 days to come back.
A positive emission tomography (PET) scan can produce a detailed, three-dimensional picture of the inside of the body. During a PET scan a substance known as a radiotracer is passed into your body. A radiotracer is a radioactive chemical that releases tiny particles called positrons.
A PET scan may be used to find out whether the cancer has spread. It may also be used for follow-up examinations after treatment to check for scar tissue or any remaining cancer cells.
Stages of oesophageal cancer
The above tests will usually determine what stage your cancer is at, what treatment you need, and the possibility of achieving a complete cure.
The stages of oesophageal cancer are described below.
- Stage zero (pre-cancer): There are no cancerous cells, but there are biological changes that could trigger the onset of cancer in the future.
- Stage 1: The cancer is limited to the top layers of the lining of the oesophagus, or is only in a small part of the oesophagus. It has not spread to nearby tissue or lymph nodes.
- Stage 2A: The cancer has spread into the layer of muscle that surrounds the oesophagus, but has not spread to nearby lymph nodes.
- Stage 2B: The cancer has spread to both the muscle layer and into nearby lymph nodes.
- Stage 3: The cancer has spread through the wall of the oesophagus into nearby lymph nodes and the surrounding tissue. However, it has not spread into other parts of the body.
- Stage 4: The cancer has spread into other parts of the body, such as your liver, lungs or stomach.
Some doctors may prefer to describe the stages of cancer using the more complex TNM staging system. The three categories are used to create a more detailed classification:
- T (tumour) – the location and size of the tumour
- N (nodes) – whether the cancer has spread to the lymph nodes
- M (metastatic) – whether the cancer has spread to other parts of the body such as the lungs, liver or bone
Read more information about how oesophageal cancer is treated.
Want to know more?
- Cancer Research UK: tests for oesophageal cancer
- Macmillan: how oesophageal cancer is diagnosed
Treatment for oesophageal cancer
Treatment options for oesophageal cancer depend on what stage the cancer is at, but may include chemotherapy, radiotherapy and surgery.
Cancer treatment team
Many primary care trusts (PCTs) have multidisciplinary teams that treat oesophageal cancer. If you have oesophageal cancer you may see several healthcare professionals as part of your treatment.
Deciding which treatment is best for you can be difficult. Your cancer team will make recommendations but the final decision will be yours.
Before going to hospital to discuss your treatment options you may find it useful to write a list of questions to ask the specialist. For example, you may want to find out the advantages and disadvantages of particular treatments.
Your treatment plan
Your recommended treatment plan will depend on what stage your cancer is at.
- Stage 1 to 3 oesophageal cancer is usually treated with a type of surgery known as an oesophagectomy (see below). Chemotherapy is usually given before surgery to reduce the risk of the cancer returning.
- In cases of stage 4 oesophageal cancer, the cancer has usually spread too far for a cure to be possible. Radiotherapy and chemotherapy can be used to slow down the spread of the cancer and to relieve symptoms.
These treatments are described in more detail below.
Want to know more?
- Cancer Research UK: treating oesophageal cancer
- Macmillan: treating gullet cancer
During an oesophagectomy your surgeon will remove the section of your oesophagus that contains the tumour and, if necessary, the nearby lymph nodes. The remaining section of your oesophagus will then be reconnected to your stomach.
To access your oesophagus your surgeon will either need to make an incision (cut) into your abdomen and chest, or into your abdomen and neck.
Self-expanding stents are another method of relieving the symptoms of dysphagia. The treatment involves placing a small metal tube into your oesophagus. The stent expands to hold open your oesophagus, which helps to make swallowing easier.
Chemotherapy is a type of cancer treatment that uses anti-cancer medicines to either kill the malignant (cancerous) cells in your body or stop them multiplying. Chemotherapy medicines can be injected or given to you orally (by mouth).
As well as attacking cancerous cells, chemotherapy can also attack normal, healthy cells in your body, which is why this form of treatment has many potential side effects.
The most common side effects of chemotherapy include:
- hair loss
- mouth sores
These side effects are usually temporary and you should find they improve on completion of your treatment.
Chemotherapy treatment is often used alongside surgery and radiotherapy (see below) to help make sure as much of the cancer as possible is treated.
Radiotherapy is a form of cancer therapy that uses high energy beams of radiation to help shrink your tumour and relieve pain.
Radiotherapy for oesophageal cancer should make it easier for you to swallow because the radiation shrinks the tumour and therefore makes it less obstructive.
The side effects of radiotherapy include:
- skin rashes
- loss of appetite
- sores in your oesophagus
These side effects are usually temporary and you should find that they improve once you have completed your treatment.
As with chemotherapy, radiotherapy is often used alongside surgery to help make the tumour easier to remove.
Another problem that can occur is a tracheoesophageal fistula. This is when the cancer creates a hole between your oesophagus and your windpipe (trachea). This may cause you to cough and gag, particularly when you try to swallow.
While surgery can be used to treat a tracheoesophageal fistula and relieve the symptoms of dysphagia, you may need to use different ways of receiving the nutrients your body needs while you are waiting for surgery.
A percutaneous endoscopic gastrostomy (PEG) tube is often used to provide your body with the nutrients it needs. A PEG is a tube placed directly into your stomach surgically. It passes through a small incision on the surface of your abdomen (tummy).
Read about how dysphagia is treated for more information about PEG tubes.
Preventing oesophageal cancer
Certain lifestyle changes can help lower the risk of getting oesophageal cancer.
Give up smoking
As well as being a significant risk factor for oesophageal cancer, smoking is also a major contributor to many serious diseases such as heart disease and lung cancer, and is the biggest cause of death and illness in the UK.
If you are committed to giving up smoking but do not want to be referred to a stop smoking service, your doctor should be able to prescribe medical treatment to help with any withdrawal symptoms you may experience after quitting.
Alcohol is another significant risk factor for oesophageal cancer, as well as for other serious conditions such as heart attack, stroke and liver disease.
The maximum recommended daily limits of alcohol consumption are:
- 3-4 units of alcohol for men
- 2-3 units for women
A unit of alcohol is equal to about half a pint of normal strength lager, a small glass of wine or a pub measure (25ml) of spirits.
If you need to lose excess weight, exercising regularly and eating a healthy, balanced diet can help. If you are very overweight or obese, losing weight will help lower your risk of developing cancer of the oesophagus.
The most successful weight loss programmes include at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity (such as cycling or fast walking) every week, eating smaller portions and only having healthy snacks between meals. A gradual weight loss of around 0.5kg (1.1lb) a week is usually recommended.
Read more about obesity and [losing weight].
A low fat, high fibre diet that includes whole grains and plenty of fresh fruit and vegetables (at least five portions a day) is recommended.
Living with cancer
A diagnosis of cancer is a tough challenge for most people and their families. There are a number of ways you can find support to help you cope with both the physical and emotional aspects.
Different things will work for different people, but some people may find it helpful to:
- make sure you keep talking to your friends and family – they can be a powerful source of support
- communicate with others in the same situation
- find out more about your condition
- set reasonable goals
- take time out for yourself
It is not always easy to talk about cancer, either for you or your family and friends. You may sense some people feel awkward around you or avoid you. Being open about how you feel and what your family and friends can do to help may put them at ease. But do not feel shy about telling them you need time to yourself, if that is what you want.
If you have questions, your doctor or nurse may be able to reassure you. You may find it helpful to talk to a trained counsellor or psychologist, or to someone at a specialist helpline. Your doctor surgery will have information on these. Some people find it helpful to talk to others who have oesophageal cancer, either at a local support group or in an internet chatroom.
Want to know more?
- Cancer Research UK: cancer chat
- Macmillan: share
- Macmillan: responding to other people
Having oesophageal cancer doesn't necessarily mean you'll have to give up work, but you may need quite a lot of time off. During your treatment you may not be able to carry on completely as before.
If you have cancer you're covered by the Disability Discrimination Act. This means your employer is not allowed to discriminate against you because of your illness. They have a duty to make 'reasonable adjustments' to help you cope. Examples of these include:
- allowing you time off for treatment and medical appointments
- allowing flexibility with working hours, the tasks you have to perform, or your working environment
The definition of what is 'reasonable' depends on the situation – for example, how much it would affect your employer's business.
It will help if you give your employer as much information as possible about how much time you will need off and when. Talk to your human resources department if you have one. Your union or staff association representative should also be able to give you advice.
If you're having difficulties with your employer, your union or your local Citizens Advice Bureau may be able to help.
Want to know more?
- Cancer Backup/Macmillan Cancer Support: work and cancer
Money and benefits
You may find it hard to cope financially if you have to reduce or stop working because of your cancer. If you have cancer, or if you're caring for someone with cancer, you may be entitled to financial support.
- If you have a job but can’t work because of your illness, you're entitled to Statutory Sick Pay from your employer.
- If you don't have a job and can't work because of your illness, you may be entitled to Employment and Support Allowance.
- If you're caring for someone with cancer, you may be entitled to Carer's Allowance.
- You may be eligible for other benefits if you have children living at home or have a low household income.
It's a good idea to find out early on what help is available. You can ask to speak to the social worker at your hospital, who will be able give you the information you need.
People being treated for cancer are entitled to apply for an exemption certificate giving free prescriptions for all medication, including prescriptions for unrelated conditions.
The certificate is valid for five years. You can apply for a certificate by speaking to your doctor or cancer specialist.
Want to know more?
- GOV.UK: benefits information
- Carers Direct: benefits for carers and benefits for the person you care for
Most people with oesophageal cancer have an operation as part of their treatment. Getting back to normal after surgery can take time. After having oesophageal surgery it will be a few days before you are able to eat or drink. To begin with, fluids will be given to you through a drip that is inserted into a vein in your arm. You may also be allowed the occasional sip of water. It is important that you do not eat or drink immediately after having surgery so that your oesophagus has time to recover.
You will be able to start consuming soft foods and liquids gradually before eventually being able to eat and drink normally, as you did before the operation.
Following surgery you may find you lose some weight. This is normal and you should regain the lost weight once you are able to eat solid foods again.
Read more information about having an operation.
Other treatments, particularly radiotherapy and chemotherapy, can make you very tired. You may need a break from some of your normal activities for a while. Do not be afraid to ask for practical help from family and friends.
After your treatment has finished you will be invited for regular check-ups, usually every three months for the first year. During the check-up your doctor will examine you, and may do blood tests and a chest X-ray to see how your cancer is responding to treatment.
Want to know more?
- Cancer Research UK: follow-up for oesophageal cancer
- Macmillan: after treatment for oesophageal cancer
- Cancer Research UK: diet after oesophageal cancer
- Macmillan: advice on diet for people affected by oesophageal cancer
If you are told there is nothing more that can be done to treat your oesophageal cancer, your doctor will still provide you with support and pain relief. This is called [palliative care]. Support is also available for your family and friends.
Want to know more?
- Marie Curie Cancer Care: information for patients and carers
After discovering he had cancer of the oesophagus in 1998, keen marathon runner Clive Alexander had an oesophagogastrectomy. Six months after his operation he was able to go running again.
"I was 63 when I first noticed symptoms. We had friends round for dinner and I swallowed a lump of bread and choked. After that, whenever I ate bread or meat I noticed it was really hard to get down. My doctor gave me a large bottle of Gaviscon medicine for indigestion and wrote a referral for me to see a specialist.
"I saw the consultant in September 1998. He gave me an endoscopy and, when the results came back, told me I had oesophageal cancer. You don't want to think the worst in these kinds of situations, but invariably you do. When I heard, I just wanted to know what could be done about it.
"I had to have two more endoscopies, and I also had an ultrasound on my liver and a CT scan. The cancer had spread to my stomach but hadn't gone further, so, in a way, I was lucky. I was referred for surgery and while I waited I carried on living as normal a life as possible. I continued working (I was a maintenance engineer, which is a very physical job involving lots of lifting) right up to my operation, and six weeks before the op I ran a half marathon.
"In December, I had an oesophagogastrectomy, an operation where the bottom of the oesophagus and half of the stomach are removed. The operation took eight and a half hours and the recovery period was meant to be two to three weeks, but because I was quite fit before surgery I was allowed home after 13 days.
"While I was in hospital I was fed semi-solid food through a tube that went straight into the small bowel. The tube was left in when I went home – just in case – and I had to clean it each day, which wasn't that nice a job.
"I do eat more normally now, but I still have to be careful. Because my stomach is half the size it used to be I can't eat large quantities. Also, the valve at the top of the stomach is no longer there, which means that if I eat too much I don't feel good. I feel very leaden and sleepy and get bad indigestion. I can go out for meals, but whereas I would once have had three courses with no problem, now I can only manage two.
"You learn to cope. I eat small meals, more often. I eat when I'm hungry rather than having three meals a day, and I don't like to eat after 5.30pm or 6pm in the evening. If I go out for a meal I have to stay up until midnight so that my food has had a chance to digest. I also have to sleep at a 45 degree angle; otherwise, you can wake up in the night feeling as if you're choking.
"I went back to work four months after the operation (although I'm retired now) and I started running again six months after the operation. I was lucky because I was fit, but having something else to focus on also helped."