What is esophageal cancer?

Esophageal cancer occurs when cancer cells develop in the esophagus, a long, tube-like structure that connects the throat and the stomach. The esophagus carries swallowed food to the stomach and is part of the upper digestive system.

There are two main types of esophageal cancer:

• squamous cell carcinoma, in which cancer develops in the thin, flat (squamous) cells that form the inner lining of the esophagus.
• adenocarcinoma, in which cancer develops in glandular cells in the lining of the esophagus.

In the early stages of esophageal cancer, there may be no symptoms. In more advanced cancers, symptoms may include:

• difficulty swallowing (feeling choked or that food gets caught)
• pain when swallowing
• weight loss
• chest pain
• coughing and regurgitation
• hoarseness
• vomiting blood
• tarry stool, or blood in stool
• indigestion and heartburn

Doctors often do not find esophageal cancer until it is at an advanced stage. It is more likely in adults over the age of 50 and twice as likely to occur in men. Besides gender and age, risk factors for esophageal cancer include:

• smoking
• heavy alcohol use
• gastroesophageal reflux disease (GERD), a condition in which the stomach contents back up into the lower section of the esophagus. This may irritate the esophagus and, over time, cause Barrett's esophagus. This is a condition in which the squamous cells lining the lower part of the esophagus have changed or been replaced with gland cells. Most people with Barrett's esophagus do not get esophageal cancer.
• The affected gland cells in Barrett's esophagus can become increasingly abnormal and lead to a pre-cancerous condition called dysplasia. If dysplasia is present or if there is a family history of Barrett's esophagus, the risk of cancer is greater.

• obesity which raises the risk by increasing reflux
• frequently drinking very hot liquids
• certain medical conditions, including achalasia (disorder that makes swallowing difficult)
• prior caustic injury to the esophagus

How is esophageal cancer diagnosed and evaluated?

Your primary doctor will ask about your medical history, risk factors, and symptoms. You will also undergo a physical exam.

Your doctor may order one or more of the following imaging tests to help determine if you have cancer and whether it has spread:

Chest x-ray: This common exam uses a very small dose of radiation to produce pictures of the inside of the chest, including the lungs, heart, and chest wall.

Computed Tomography (CT) - Chest: This exam uses x-ray technology to produce multiple images of the inside of the body. The cross-sectional images generated during a CT scan can be reformatted in multiple planes and can even generate three-dimensional images. These images can be viewed on a computer monitor, printed on film, or transferred to a CD or DVD.

X-ray (Radiography) - Upper GI Tract: Upper gastrointestinal tract radiography is also known as upper GI. It uses a form of real-time x-ray called fluoroscopy and a barium-based contrast material to produce images of the esophagus, stomach, and small intestine. The oral contrast material coats the esophagus and stomach, and the doctor takes a series of x-rays. An upper GI exam that focuses on the esophagus is called a barium swallow or an esophagram.

Upper Endoscopy or Esophagogastroduodenoscopy (EGD): This procedure uses an endoscope, a thin, flexible tube with a light and a small camera at the tip inserted through the mouth. It allows the physician to view the lining of the esophagus, stomach, and the first part of the small intestine (duodenum) directly. The patient is given sedation to stay relaxed and comfortable, and the doctor inserts the scope through the mouth and down the throat. Some scopes have tools to remove tissue samples for inspection under a microscope for signs of cancer.

Endoscopic ultrasound or Endosonography (EUS): This procedure uses an endoscope, a thin, flexible tube with a light and a small camera at the tip inserted through the mouth. The patient is given sedation to stay relaxed and comfortable. A probe at the end of the endoscope bounces high-energy sound waves (ultrasound) off internal structures to create echoes. The echoes form a picture of body tissues called a sonogram. For esophageal cancer, EUS helps show how deep a tumor has grown and whether nearby lymph nodes are affected, which helps guide treatment.  

Positron Emission Tomography/Computed Tomography (PET/CT): PET uses small amounts of radioactive materials called radiotracers, a special camera, and a computer to help evaluate your organ and tissue functions. By identifying body changes at the cellular level, PET may detect the early onset of disease before it is evident on other imaging tests. PET/CT can detect esophageal cancer and determine if it has spread. It can also assess the effectiveness of a treatment plan and determine if the cancer has returned after treatment.

If these tests do not clearly show that an abnormality is benign, a biopsy is necessary. In a biopsy, a sample of tissue is removed for examination in a lab. Biopsies can be used in different ways to obtain tissue samples. Some biopsies remove a small amount of tissue with a needle. Others may surgically remove an entire lump (nodule) that is suspicious. If an upper endoscopy reveals the presence of Barrett's esophagus, your doctor will take a biopsy. This will help them rule out dysplasia (precancerous changes) and/or adenocarcinoma.

Your doctor will use these test results to help determine the presence and extent or stage of esophageal cancer.

If these tests are not suspicious for cancer, no further steps may be needed. However, your doctor may want to monitor the area during future visits. Barrett's esophagus frequently requires close follow-up and/or monitoring. Your doctor will use upper endoscopy to determine if your condition progresses to dysplasia.

How is esophageal cancer treated?

Treatment for esophageal cancer may include surgery, radiation therapy, chemotherapy, and targeted therapy or immunotherapy. The optimal combination of treatments will depend on the type, location, and stage of the disease. Some therapy may only be available in clinical trials. See the Clinical Trials page for more information. The earlier esophageal cancer is found, the better chance of recovery. Late-stage esophageal cancer can be treated but rarely can be cured.

Surgery: Surgery is an important treatment for esophageal cancer. For early-stage disease it may be used on its own, while for more advanced tumors it is usually combined with other therapies, often after chemotherapy and radiation given to shrink the tumor first. For a very small tumor confined to the innermost lining of the esophagus, the abnormal tissue can often be removed through an endoscope (a procedure called endoscopic resection) rather than with open surgery. In more advanced cancers, a surgeon may remove part of the esophagus in an operation called an esophagectomy. Surgeons frequently use a minimally invasive approach. Working through small incisions between the ribs and in the abdomen, the surgeon uses a thoracoscope, a thin, tube-like instrument with a light and a camera, and in some centers a surgical robot, to remove the affected part of the esophagus. The surgeon removes the cancerous portion of the esophagus along with nearby lymph nodes. They re-connect the remaining esophagus to the stomach or part of the patient's gastrointestinal (GI) tract. In an esophagogastrectomy, the surgeon removes the diseased part of the esophagus, nearby lymph nodes, and part of the stomach if the cancer has spread near or into the stomach.

Radiation therapy: This treatment uses high-energy x-rays or other types of radiation to kill cancer cells. For esophageal cancer it is most often given together with chemotherapy, a combination called chemoradiation, because the two work better in tandem than either does alone. Chemoradiation may be used before surgery to shrink the tumor and improve the chances of removing it completely (called neoadjuvant treatment). In some cases, particularly for tumors in the upper esophagus where surgery is not possible or for patients who are not deemed eligible for surgery, chemoradiation is used as the main treatment (called definitive treatment). Radiation may also be given after surgery (called adjuvant therapy) in selected cases, for example when a patient did not receive radiation beforehand and cancer cells were left behind at the edge of the removed tissue (a positive margin). They may also use it to help manage the symptoms and complications of advanced disease, including pain and tumor growth that prohibits food from passing to the stomach. See the Introduction to Cancer Therapy (Radiation Oncology) page for more information.

Chemotherapy: This treatment uses chemical substances or drugs to kill cancer cells or stop them from dividing. Doctors may use chemotherapy before or after surgery for esophageal cancer and in combination with radiation therapy. Chemotherapy also helps relieve symptoms when esophageal cancer has spread (metastasized) beyond the esophagus.

Other treatments for esophageal cancer include:

Chemoprevention: Drugs, vitamins, and other agents are being studied in an effort to try and reduce the risk of cancer and/or delay its development or recurrence. For instance, proton pump inhibitors and aspirin have been studied for their potential to lower the risk that Barrett's esophagus progresses to cancer.

Radiofrequency ablation (RFA): This procedure uses heat energy to destroy the abnormal lining in Barrett's esophagus. Doctors may use it to treat Barrett's esophagus that contains dysplasia, with the goal of preventing progression to adenocarcinoma

Targeted therapy (including Monoclonal Antibody Therapy): A small number of esophageal cancers have too much of a protein called HER2 on the surface of their cells. A drug known as trastuzumab (Herceptin) is a monoclonal antibody that attaches to the HER2 protein on cancer cells and interferes with their ability to grow. Another target is a protein called Claudin 18.2, found on the surface of some esophageal and stomach cancer cells, which can be treated with a newer antibody called zolbetuximab. Doctors test the tumor tissue to determine which of these targets, if any, are present. The doctor may combine targeted therapy with chemotherapy.

Immunotherapy: This approach uses drugs that help the patient's own immune system recognize and attack cancer cells. Several immunotherapy drugs are now an established part of treatment. It can be combined with chemotherapy for advanced or metastatic esophageal cancer. May be given after chemoradiation and surgery when residual cancer is found in the removed tissue, which can lengthen the time before the cancer returns. For tumors lower in the esophagus, near the stomach, immunotherapy can be given together with chemotherapy before surgery and continued afterward, an approach shown to improve survival.  

Nutrition and Swallowing Support: Esophageal cancer can affect a person's ability to eat and swallow. Therefore, additional treatments may be necessary to ensure proper nutrition during and after treatment. Some patients may receive nutrients directly into a vein. Others may require a feeding tube that delivers liquid nutrition directly into the stomach or small intestine. This is a flexible plastic tube that passes through the nose or mouth into the stomach. Tubes used for longer-term feeding are usually placed directly through the skin of the abdomen. In some cases, a stent (a small expandable tube) may be placed to hold the esophagus open and make swallowing easier. The doctor will leave the tube or stent in place until they are able to eat on their own.

Which test, procedure or treatment is best for me?

Esophageal cancer is best managed by a team of specialists working together, often including a gastroenterologist, surgeon, medical oncologist, radiation oncologist, and a nutrition specialist. This team reviews your test results together and recommends a plan tailored to your situation.

Staging and Follow-up of Esophageal Cancer