Esophageal cancers develop in the cells that line the wall of the esophagus (the tube that connects the throat to the stomach).
Tobacco and alcohol use, gastroesophageal reflux, and obesity are risk factors for esophageal cancer.
Typical symptoms include difficulty swallowing, weight loss, and, later, pain.
The diagnosis is based on an endoscopy and biopsy.
Surgery, chemotherapy, and various other therapies can help relieve the symptoms.
Unless discovered early, almost all cases of esophageal cancer are fatal.
Worldwide in 2018, esophageal cancer was the 7th most commonly diagnosed type of cancer and the 6th leading cause of cancer deaths with about 572,000 new cases and 508,000 deaths.
In the United States, esophageal cancer is not as common. In the United States in 2023, cancer of the esophagus will account for an estimated 21,560 new cases and 16,120 deaths.
The most common types of esophageal cancer develop in the cells that line the wall of the esophagus and include
Squamous cell carcinoma, which is more common in the upper part of the esophagus
Adenocarcinoma, which is more common in the lower part
These cancers may appear as a narrowing (stricture) of the esophagus, a lump, an abnormal flat area (plaque), or an abnormal connection (fistula) between the esophagus and the airways that supply the lungs.
Squamous cell carcinoma is the most common esophageal cancer worldwide, but, in the United States, adenocarcinoma is more common. In the United States, squamous cell carcinoma is more common among men than women and more common among Black than White people.
Less common types of esophageal cancer include leiomyosarcomas (cancers of the smooth muscle of the esophagus) and metastatic cancer (cancer that has spread from elsewhere in the body).
Risk Factors for Esophageal Cancer
The main risk factors for esophageal cancer are
Alcohol
Tobacco use (in any form)
Gastroesophageal reflux disease (especially for adenocarcinoma)
Obesity (especially for adenocarcinoma)
Older age
Male sex
Barrett esophagus
Genetic syndromes (for example, Bloom syndrome and Fanconi anemia)
Other risk factors include human papillomavirus infection, radiation therapy to the esophagus for treatment of other nearby cancers, achalasia, esophageal webs (Plummer-Vinson syndrome), or narrowing due to having once swallowed a corrosive substance (such as lye).
Most adenocarcinomas develop in people who have a precancerous condition called Barrett esophagus. Barrett esophagus develops from prolonged irritation of the esophagus caused by the repeated backflow of stomach acid (gastroesophageal reflux). People who have obesity have an increased risk of adenocarcinoma because of their higher risk of gastroesophageal reflux.
Symptoms of Esophageal Cancer
Early-stage esophageal cancer may not cause any symptoms.
As the growing cancer narrows the esophagus, the first symptom of esophageal cancer is usually difficulty in swallowing solid foods. Several weeks later, swallowing soft foods and then liquids and saliva becomes difficult.
Weight loss is common, even when the person continues to eat well. People may have chest pain, which feels like it travels to their back.
As the cancer progresses, it commonly invades various nerves and other tissues and organs. The tumor may compress the nerve that controls the vocal cords, which can lead to hoarseness. Compression of surrounding nerves may cause spinal pain, paralysis of the diaphragm, and hiccups.
The cancer usually spreads to the lungs, where it may cause shortness of breath, and to the liver, where it may cause fever and abdominal swelling. Spread to bones may cause pain. Spread to the brain may cause headache, confusion, and seizures. Spread to the intestines may cause vomiting, blood in the stool, and iron deficiency anemia. Spread to the kidneys often causes no symptoms.
In late stages, the cancer may completely block the esophagus. Swallowing becomes impossible, so secretions build up in the mouth, which can be very distressing.
Diagnosis of Esophageal Cancer
Endoscopy and biopsy
Barium swallow
Computed tomography (CT)
PET-CT and ultrasonography
Endoscopy, in which a flexible viewing tube (endoscope) is passed through the mouth to view the esophagus, is the best diagnostic procedure if esophageal cancer is suspected. Endoscopy also allows the doctor to remove a tissue sample (biopsy) and loose cells (brush cytology) for examination under a microscope.
An x-ray procedure called a barium swallow (in which the person swallows a solution of barium, which shows up on x-rays) can also show the obstruction.
Once esophageal cancer is identified, doctors do computed tomography (CT) of the chest, abdomen, and pelvis as well as positron emission tomography (PET-CT) of the whole body to determine how far the tumor has spread. Ultrasonography done through an endoscope (see ultrasound scanning) inserted in the esophagus may be used to further assess the extent of the cancer.
Basic blood tests are done.
Treatment of Esophageal Cancer
Surgical removal
Chemotherapy combined with radiation (chemoradiation)
Immunotherapy combined with chemotherapy for advanced cancer
Relief of symptoms
Doctors sometimes treat shallow (superficial) adenocarcinomas by doing endoscopic resection, which means the adenocarcinomas are removed during the endoscopy. Endoscopic resection is less invasive and thus less risky than doing a surgical operation to remove the cancer. People whose cancer is removed early may not require chemotherapy or radiation. However, most esophageal cancers are treated with chemoradiation (see Combination Cancer Therapy) before surgery is done. Sometimes chemoradiation done before surgery can increase survival.
Immunotherapy involves giving medications that stimulate the body's immune system to fight the cancer. These treatments target specific genetic characteristics of the tumor cells. Immunotherapy is sometimes given after tumor resection. Immunotherapy combined with chemotherapy is the recommended treatment for advanced squamous cell carcinoma of the esophagus and may be recommended for treatment of adenocarcinoma of the esophagus.
Other measures are aimed at relieving symptoms, particularly difficulty swallowing. Such measures include stretching open the narrowed area of the esophagus and then inserting a flexible metal mesh tube (a stent) to keep the esophagus open, burning the cancer with a laser to widen the opening, and using radiation therapy to destroy the cancer tissue obstructing the esophagus.
Shallow (superficial) adenocarcinomas sometimes are cured by being burned away with radio waves (radiofrequency ablation).
Another technique for symptom relief is photodynamic therapy, in which a light-sensitive dye (contrast agent) is given by vein (intravenously) 48 hours before treatment. The dye is absorbed by cancer cells to a much greater degree than by the cells of normal surrounding esophageal tissue. When activated by light from a laser passed into the esophagus through an endoscope, the dye destroys cancer tissue, thus opening the esophagus. Photodynamic therapy destroys obstructing lesions more rapidly than radiation or chemotherapy in people who cannot tolerate surgery because of poor health.
Adequate nutrition makes any type of treatment more feasible and tolerable. People who can swallow may receive concentrated liquid nutritional supplements. People who cannot swallow may need to be fed through a tube placed through the wall of the abdomen into their stomach (gastrostomy tube).
Prognosis for Esophageal Cancer
Because esophageal cancer usually is not diagnosed until the disease has spread, the death rate is high. Fewer than 5% of people survive more than 5 years. Many die within a year of noticing the first symptoms. Exceptions include adenocarcinomas that are diagnosed when they are still very shallow (superficial).
Because nearly all cases of esophageal cancer are fatal, the doctor’s main objective is to control symptoms, especially pain and difficulty swallowing, which can be very frightening to the person and loved ones.
Because death is likely, a person with esophageal cancer should make all necessary plans. The person should have frank discussions with the doctor about wishes for medical care (see Advance Directives) and the need for end-of-life care.
