Esophageal Cancer

What esophageal cancer is

The esophagus is about 25 cm (10 inches) long and runs behind the windpipe and heart to the stomach. Its inner lining is made of flat (squamous) cells. Cancer starts when cells in the lining grow uncontrollably and invade deeper into the wall, then into nearby lymph nodes and organs.

Because the esophagus stretches easily, a tumor often has to narrow the passage by more than half before swallowing becomes difficult. That is one reason esophageal cancer is often found at a later stage.

Types of esophageal cancer

Rare types include neuroendocrine tumors, lymphoma and gastrointestinal stromal tumors (GIST).

Esophageal cancer symptoms

Early signs

Early esophageal cancer often causes no symptoms. It is sometimes found during endoscopy for reflux or Barrett's surveillance. Possible early signs include:

• a feeling of food sticking behind the breastbone
• new or worsening heartburn or indigestion
• mild discomfort or burning when swallowing

Later symptoms

• Difficulty swallowing (dysphagia): the hallmark. It typically starts with dry, bulky foods such as bread and meat, then progresses to soft food and finally liquids, over weeks to months.
• Painful swallowing (odynophagia)
• Unexplained weight loss, from eating less and the cancer itself
• Regurgitation of food, vomiting, and coughing or choking when eating
• Chest or upper back pain
• A hoarse voice if the tumor affects the nerve to the voice box
• Persistent cough, or pneumonia from food entering the lungs
• Tiredness and paleness from slow bleeding (iron deficiency anemia); occasionally vomiting blood or black stools

Causes and risk factors

• Long-term GERD: acid and bile damage the lining. Barrett's esophagus raises adenocarcinoma risk, though the yearly risk for any one person with Barrett's is low (about 0.1% to 0.5% per year without dysplasia).
• Obesity, particularly fat around the abdomen.
• Tobacco in any form, and alcohol: together they multiply the risk of squamous cell cancer.
• Very hot drinks (above about 65 °C, 149 °F).
• Achalasia, a swallowing disorder, raises squamous cell risk many years later.
• Previous head and neck cancer, and previous chest radiation.
• Caustic injury from swallowing lye in the past.
• Rare inherited conditions such as tylosis (thickened skin on palms and soles).
• Age and sex: most people are diagnosed after 60; men are affected about 3 to 4 times as often as women.

How it is diagnosed

1. Upper endoscopy (EGD): a thin camera is passed down the throat under sedation to look at the lining and take biopsies. This is the key test.
2. Barium swallow: a contrast X-ray sometimes done first to show narrowing.
3. CT scan of the chest, abdomen and pelvis to look for spread.
4. PET-CT to find spread to distant lymph nodes or organs.
5. Endoscopic ultrasound (EUS): shows how deep the tumor goes into the wall and whether nearby lymph nodes are involved.
6. Laparoscopy for some tumors near the stomach, to check the lining of the abdomen.
7. Biomarker tests on the biopsy, such as HER2, PD-L1 and mismatch repair status, which guide drug treatment.

Esophageal cancer stages

Staging uses the TNM system (tumor depth, lymph nodes, metastasis).

Treatment

A specialist team (surgeon, medical and radiation oncologists, gastroenterologist, dietitian) plans treatment based on stage, type, location and general fitness.

Very early cancer

Endoscopic resection (endoscopic mucosal resection or submucosal dissection) removes the cancer through the endoscope, often followed by ablation of remaining Barrett's tissue. No external incision is needed.

Localized cancer (stages I to III)

• Neoadjuvant therapy, then surgery: chemoradiation or chemotherapy before surgery shrinks the tumor and improves survival.
• Esophagectomy: removal of most of the esophagus, with the stomach pulled up into the chest to form a new food pipe. It is major surgery with a hospital stay of 1 to 2 weeks and a recovery of several months.
• Definitive chemoradiation: for squamous cell cancers, especially in the upper esophagus, or for people not fit for surgery.
• Immunotherapy after surgery: offered to some people who still have cancer in the removed tissue.

Advanced cancer

• Chemotherapy combined with immunotherapy, and targeted drugs such as trastuzumab for HER2-positive adenocarcinoma.
• Relieving swallowing: an esophageal stent, short-course radiation, or a feeding tube.
• Palliative care to manage pain, nutrition and quality of life.

Nutrition

Many people lose weight before diagnosis. A dietitian may suggest soft, high-calorie foods, nutritional drinks or temporary tube feeding. After esophagectomy, people eat small, frequent meals and may experience dumping syndrome or reflux, which can be managed.

Outlook

Survival depends heavily on stage. In the US, 5-year relative survival is roughly 49% when cancer is localized, about 28% with regional spread and about 6% with distant spread (American Cancer Society, based on SEER data). Results continue to improve with combined treatment and immunotherapy.

Prevention and early detection

• Stop smoking and limit alcohol.
• Keep a healthy weight and treat persistent reflux.
• Let very hot drinks cool before drinking.
• People with long-standing reflux plus risk factors may be offered screening endoscopy for Barrett's esophagus. Those with Barrett's have surveillance endoscopy every 3 to 5 years, more often with dysplasia, which can be treated before cancer forms.

Frequently asked questions

What are the first signs of esophageal cancer?

The most common first sign is food sticking in the chest, starting with solid food and gradually worsening. Other early clues are new or worsening heartburn, discomfort when swallowing, and unintended weight loss. Early cancer can also cause no symptoms at all and be found during endoscopy.

Who is most at risk for esophageal cancer?

Risk is highest in people over 60, men, smokers, heavy drinkers, and people with long-term acid reflux, Barrett's esophagus or obesity. Achalasia, previous head and neck cancer and drinking very hot beverages also raise the risk.

Does acid reflux turn into esophageal cancer?

Most people with reflux never develop cancer. Long-term reflux can cause Barrett's esophagus, which slightly raises the risk of adenocarcinoma. Controlling reflux, keeping a healthy weight and surveillance endoscopy for Barrett's help catch changes early.

How fast does esophageal cancer spread?

It varies. Many tumors grow over months to years before causing symptoms. The esophagus has a rich lymphatic network and no outer protective layer (serosa), so cancer can reach lymph nodes relatively early. That is why progressive swallowing difficulty should be checked promptly.

What is the survival rate for esophageal cancer?

Overall 5-year relative survival in the US is about 1 in 5, but it varies widely by stage: around half for localized cancer and much lower once it has spread. Very early cancers removed endoscopically have an excellent outlook.

Can you live without an esophagus?

Yes. After esophagectomy, the stomach is usually reshaped into a tube and pulled up to join the remaining esophagus in the chest or neck. People eat smaller, more frequent meals and must avoid lying flat after eating, but most return to eating by mouth.