Author and provocateur Christopher Hitchens, 61, announced this week he would cut short a book tour for his new memoir, "Hitch-22," because he will undergo chemotherapy for esophageal cancer, a serious diagnosis that rarely has a happy ending.
The disease kills 14,530 Americans a year and one type -– squamous cell carcinoma -– is associated with smoking and drinking, habits Hitchens extolled as virtues in essays and features for Vanity Fair magazine.
"It tends to be an aggressive cancer," said Dr. Richard Battafarano, chief of thoracic surgery at the University of Maryland. "By the time a person knows he has esophageal cancer, it's already moved to stage 3 or 4. By the time people go to the doctor because their voice has changed or their swallowing has changed, the tumor has advanced."
Speculation has already begun on what role Hitchens' self-proclaimed hedonistic lifestyle played in his diagnosis.
"The fact that people are also calling it throat cancer tells me it's high up behind the voice box," said Battafarano. "We know he had a prolific consumption of alcohol and cigarettes and he had quit smoking, but it might be a little late."
The British-American author's statement on his publisher's website had little detail.
"I have been advised by my physician that I must undergo a course of chemotherapy on my esophagus," he wrote. "This advice seems persuasive to me. I regret having had to cancel so many engagements at such short notice."
If the cancer is localized and has not yet spread, Hitchens would likely not get chemotherapy alone, according to Battafarano. At the same time, he may have refused surgery, which can damage the nerves around the voice box.
"He could have told the surgeon, No way I am risking my voice box,'" Battafarano said. "It's hard to guess. If it's outside of the esophagus and he's getting chemotherapy because [the cancer] has metastasized, that's not good. It they are using a strategy that starts with chemotherapy and moves into radiation next, it could be localized."
"[Hitchens] is being very private, as he should be," said Battafarano. "We could be wildly wrong or right on."
As the author of more than dozen books and magazine features, many of them about his personal proclivities, Hitchens often celebrated his love of Johnny Walker Black.
Christopher Hitchens, Provocative Author, Battles Cancer
"What the soothing people at Alcoholics Anonymous don't or won't understand is that suicide or self-destruction would probably have come much earlier to some people if they could not have had a drink," he wrote in a 2003 essay on booze, "Living Proof."
Hitchens gave up tobacco in 2008, but had been seen sneaking a puff or two, according to the Washington Post. His wife Carol Blue said it was "fear" and a desire to "live to see his political enemies defeated."
Another drinker and chain smoker, Humphrey Bogart, died of esophageal cancer at age 57 reportedly uttering the famous last words "I never should have switched from scotch to martinis."
Other celebrities who died of the disease included Texas Governor Ann Richards and actor Ron Silver.
There are several types of esophageal cancer, all of which form in the muscular tube where food passes from the throat to the stomach. The most serious forms of the disease are squamous cell carcinoma and adenocarcinoma.
Studies have shown smoking and drinking can contribute to the risk of squamous cell esophageal cancer, but statistically that may not be the case with Hitchens. Most of the time, white middle-aged men succumb to adenocarcinoma, which can be caused, in part, by acid reflux, according to doctors.
The National Institutes of Health (NIH) reports that 16,470 new cases of the disease were reported in 2009.
"It's one of the worst cancers and the reason is because it's so easy to metastasize," said Dr. Fritz Francois, assistant professor at New York University and a gastroenterologist who does research on esophageal cancer. "If you think about it as a tube and on the outside is a network of blood vessels and lymph nodes."
Those age 65 years or older are at the highest risk of getting esophageal cancer, according to the NIH. Men are three times as likely to develop the disease, especially those who drink more than three alcoholic beverages a day; smokers, too are at high risk, and the combination of the two increase the chances of developing the disease exponentially.
The main function of the cells in the esophagus are to protect the rest of the body.
Christopher Hitchens, Provocative Author, Battles Cancer
"Not only do the cells protect against the stomach acid coming up, things move forward and we swallow a lot of things we shouldn't," said Francois. "If you are a smoker, although the smoke goes to the lungs, anything that coats your mouth, you can swallow and expose the cells to carcinoma."
"Think about them like pancake layers, one stacked on top of the other,' said Francois. "There are about 40 of them stacked on top to form a barrier on the esophagus."
The rate of squamous cell carcinoma is highest in African American men – about 28 cases out of 100,000 as compared to 3 out of 100,000 in the general population.
The second major type of esophageal cancer is adenocarcinoma, which occurs in the gland-forming cells near the swallowing tube's junction with the stomach. That disease is associated with acid reflux damage. About 2 to 3 in 100,000 will get this type of esophageal cancer; the risk is double -- 5 in 100,000 -- for white men, according to Francois.
As the tube approaches the stomach –- at the gastroesophageal junction –- the cells of the esophagus transition to the cells of the stomach and become more column-like. It is there that adenocarcinoma strikes.
"Those cells stand taller and their function is different," he said. "That lining has other specialized cells that work like a team, like a basketball guard that makes acid cells and other protein."
In a condition called Barrett esophagus, abnormal cells develop to protect the lower esophagus from acid, increasing the risk for adenocarcinoma. Most people don't know they have it, according to Francois.
Symptoms for both squamous cell and adenocarcinoma include difficulty in swallowing, weight loss, pain swallowing or anemia. In some cases, patients vomit up blood. "At that point, the thing has been there for a while, and our chance of picking it up at an early stage is rare," he said.
The reason survival rates are not as good as other cancers is that patients are often diagnosed too late. "If the person is lucky, they are there for another reason and we pick it up early at stage 1," he said.
At stage 1, the cancer is just on the surface of cells; stage 2 the disease has entered the muscle wall; state three it has gone through the entire wall; and in stage 4, the cancer has spread.
"Most of the time, it's picked up in stage 3 or 4," he said.
Esophageal cancer, depending on its type or stage or other factors, can be treated with surgery, chemotherapy or radiation. Squamous cell cancer seems to be more receptive to radiation.
Early studies have shown that patients who get radiation treatment alone in this early form of cancer have a survival rate of 60 percent, according to Francois.
As in all cancers, three factors are involved in assessing a person's risk: genetic make-up, environmental factors like toxins (including smoking and drinking); and perhaps, new studies are showing, microbacteria in the stomach, like H-pilori.
Interestingly, stomach cancer is associated with H-pilori, according to research, but the bacteria seem somewhat "protective" for adenocarcinoma of the esophagus.
"For the average American, I wouldn't recommend screening," said Francois. "However if you have symptoms of acid reflux and they are not going away and not being treated with acid blockers, I would see a doctor to be evaluated."
Those with trouble swallowing or who have had symptoms of acid reflux for more than 10 years and are in a high-risk group like white males, should seek a one-time endoscopy to evaluate for Barrett's esophagus, said Francois.
"Then we can follow you and make sure it doesn't transition to cancer," he said.
There are no such tests for squamous cell cancer, short of a biopsy of the esophagus, for heavy smokers and drinkers like Hitchens.
Those who do drink should consider cutting back, something Hitchens -– in his own inimitable way -– said that he has done.
"There was a time when I could reckon to outperform all but the most hardened imbibers, but I now drink relatively carefully," he wrote in "Hitch-22," describing his working day.
"At about half past midday, a decent slug of Mr. Walker's amber restorative, cut with Perrier water (an ideal delivery system) and no ice. At luncheon, perhaps half a bottle of red wine: not always more but never less. Then back to the desk, and ready to repeat the treatment at the evening meal. No 'after dinner drinks' -- most especially nothing sweet and never, ever any brandy. 'Nightcaps' depend on how well the day went, but always the mixture as before. No mixing: no messing around with a gin here and a vodka there."