Esophageal (Oesaphageal) cancer is a cancer of the esophagus, it can be extremely aggressive and has a poor survival rate. The esophagus is a long connective tube (food pipe) joining your throat and stomach together. Its purpose is to facilitate the movement of food you have swallowed into your stomach in preparation for digestion. Cancer of the esophagus can develop anywhere along the esophageal passage. Cancer beginning in cells that line the upper and middle esophagus (squamous cells) is known as esophageal squamous cell carcinoma (ESCC), this is the most prevalent esophageal cancer worldwide. Esophageal cancer that begins in the gland cells located at the bottom of the esophagus is known as esophageal adenocarcinoma (EAC), this primarily affects white men and is the most prevalent esophageal cancer in the US.1
As with most cancers, esophageal cancer is highly curable when detected and treated early. If the cancer has progressed towards the later stages, cancer of the esophagus usually is fatal and treatment can only help alleviate symptoms.2
- Brief overview of esophageal cancer
- Importance of early detection and treatment
Symptoms of esophageal cancer
According to the American Cancer Society esophageal cancer is generally diagnosed following the onset of disease symptoms. Once, disease symptoms are present the esophageal cancer usually is advanced. The more advanced the esophageal cancer is, the more difficult it is to treat.2
Common esophageal cancer symptoms listed by the American Cancer Society are:
- Trouble swallowing is also known as dysphagia. This feels like food stuck in the throat or chest. This symptom may go unnoticed initially but will worsen as the cancer grows, this can lead to choking. People may change their eating habits before realising they are having difficulty swallowing. If the cancer has become large enough to restrict the passage of food through the esophagus, swallowing may be painful
- Chest pain or discomfort is often felt in the middle part of the chest in those with esophageal cancer. Some individuals with this type of cancer experience burning or pressure in the chest, however, these are more commonly associated with conditions such as heartburn
- Unintended weight loss is often seen in individuals with esophageal cancer due to trouble swallowing reducing the amount someone can eat. Cancer can also increase a person's metabolism and decrease their appetitie
- Hoarseness or Chronic cough that does not go away is a symptom of esophageal cancer
- Bleeding into the esophagus can cause stool to appear black due to the blood passing through your digestive system. Anemia may develop as a result of this blood loss
Causes and risk factors
Esophageal cancer is caused by malignant (cancer) cell growth in the lining of the esophagus. Malignant cells are caused by genetic mutations in a cell's DNA. Mutations in DNA are randomly happening in all of our cells all the time and most do not cause cancer. However, in our DNA we have genes which code for things like cell death, cell growth and cell division, if mutations happen in some of these genes, cancer may begin.3 Various lifestyle and genetic factors can increase the number of random mutations happening in your cells, and as a result they increase the likelihood of a mutation in a cancer causing gene.4
Factors that are linked to an increased risk of esophageal cancer include:
- Chronic Acid Reflux (GERD): Gastroesophageal reflux disease (GERD) is a known risk factor for esophageal cancer, particularly for esophageal adenocarcinoma. Individuals that suffer with GERD symptoms weekly have a five-fold increased risk of developing EAC, and those who experience daily GERD symptoms have a seven-fold increased risk5
- Barret’s Esophagus: AboutGerd.Org describes Barret’s esophagus as a condition that results from severe, chronic GERD. Individuals with Barret’s esophagus have a 30 to 60-fold increased risk of developing esophageal adenocarcinoma5
- Smoking and Alcohol Use: Both smoking and alcohol consumption are strongly associated with an increased risk of developing esophageal squamous cell carcinoma5
- Obesity: There is a strong association between obesity and the development of esophageal adenocarcinoma. Esophageal adenocarcinoma risk is 16 times more likely in those with a BMI of 30 or greater, compared to individuals with a BMI of 22 or less5
- Age and Gender: Both types of esophageal cancer (ESCC and EAC) are more common in males than females.5 According to Cancer.Net people who are between 45 and 70 are at the highest risk of esophageal cancer
- HPV: The human papillomavirus (HPV) is often linked to disease-risk in certain cancers. Current literature may associate HPV infection with esophageal squamous cell carcinoma, however, at the moment there isn’t enough evidence to confirm this link5
Other risk factors mentioned by the mayoclinic include difficulty swallowing, frequently drinking very hot liquids and a diet lacking in an adequate amount of fruit and vegetables.
Diagnosis and staging
Generally esophageal cancer is not diagnosed until it reaches an advanced stage. This is due to the lack of symptoms in the earlier stages of the disease. Therefore, if you are experiencing any esophageal cancer symptoms it is crucial to seek medical assistance early whilst the cancer is still treatable.
- Medical history and physical exam: Your doctor will begin by asking about your symptoms and your medical history. Your doctor will also examine you to identify any physical symptoms of esophageal cancer or other health concerns
- Biopsy and tissue sampling: When testing for esophageal cancer, a doctor may perform an endoscopy with a biopsy, this may be referred to as an esophagogastroduodenoscopy. It involves using a narrow flexible tube, with a camera at the end to look for abnormalities in this area. If abnormalities are observed your doctor may take a tissue sample (known as a biopsy) to confirm a diagnosis
- Imaging tests: Following diagnosis of esophageal cancer after a biopsy, your doctor may wish to perform different imaging tests to determine the spread of cancer. The most accurate imaging test following esophageal cancer diagnosis is an endoscopic ultrasonography. This test combines an endoscopy and an ultrasound to produce detailed images of the esophagus. A PET scan may be used to assess the spread of cancer beyond the esophagus, for this, radioactive dye is used to highlight areas of the body that may be cancerous. In addition, following most cancer diagnosis at CT scan is used to determine how advanced a tumor is
Staging of cancer (TNM system)
Following diagnosis with esophageal cancer, your cancer will be classified according to the TNM classification system. This is used to classify malignancy and can be used to estimate prognosis and determine treatment options.6
T: This represents the size of the tumor and whether it has invaded into localised tissues. T0 suggests no there is no tumor, and T1-4 are used to describe the size and invasion of the tumor in ascending order.
N: The ‘N’ is used to indicate whether the cancer has spread to the lymph nodes. N0 indicated no spread, and N1-3 describe the cancer spread to the lymph nodes progressively. If yut lymph nodes are unable to be assessed, Nx will be used.
M: ‘M’ describes whether the tumor has metastasized (spread). M0 indicates that no distant metastasis is present and M1 is used if there is evidence of metastasis. M1 can further be broken down into M1a, M1b and M1c.6
According to the National Cancer Institute there are different treatment types available to individuals with esophageal cancer. These tend to be used as a combination and aim to target your cancer as specifically as possible. There are currently 7 different treatment types available to patients with esophageal cancer. These are:
- Surgery: Part or all of the esophageal tumor is removed, surrounding esophageal tissue may also be removed. The doctor will then reconnect the remaining esophagus to the stomach
- Radiation therapy: This uses radiation to kill cancer cells or prevent their growth
- Chemotherapy: This involves the use of drugs to kill cancerous cells or to stop them dividing
- Chemoradiation therapy: This is a combination of both radiation therapy and chemotherapy. This approach can increase the effectiveness of both
- Laser therapy: This involves the use of a laser beam to kill cancer cells
- Electrocoagulation: This uses an electric current to kill cancer cells
- Immunotherapy: This harnesses the patient's immune system to fight the cancer
As a result of late diagnosis, esophageal cancer has a poor prognosis. Only around 20% of people will survive 5 years following an esophageal cancer diagnosis. Once diagnosed 60% of patients will only be suitable for palliative care. Palliative care is aimed at reducing patient suffering.7
Treatment for symptom relief and quality of life
Dysphagia (a difficulty swallowing) is one of the more distressing symptoms of the disease affecting quality of life. As a result the palliative care for the disease heavily centers around relieving this symptom.7
Support for patients and families
Caring for someone with esophageal cancer can be very stressful and take a huge emotional toll. It is important that whilst acting as a caregiver to a loved one you remember to care for yourself. There are various charities and organizations to help alleviate the stress of caring for a loved one depending on the country you reside in.
Prevention and screening
Lifestyle changes (quit smoking, limit alcohol, etc.)
To decrease your risk of developing esophageal cancer it is important you maintain a healthy diet, quit smoking and reduce your alcohol intake.
Screening for high-risk individuals
For individuals with Barrett's esophagus routine screening for cell dysplasia may be recommended.
Early detection and treatment
As with most cancer types, if it is detected early it is more likely to be treatable. As mentioned above, this disease is generally diagnosed once the cancer has become advanced, however, hopefully in the future there will be more screening options available allowing us to detect the disease before it reaches these advanced stages.
Esophageal cancer is a cancer of the esophagus. One of the main symptoms is dysphagia (a difficulty swallowing), if you are experiencing this symptom you should seek medical advice. The symptoms of this disease usually only become present once the cancer has reached an advanced state. There are many different treatment options available that your healthcare provider can discuss with you. These can be aimed at curing the cancer or to palliate the symptoms of the disease.
- Melhado RE, Alderson D, Tucker O. The changing face of esophageal cancer. Cancers [Internet]. 2010 Sep [cited 2023 Mar 31];2(3):1379–404. Available from: https://www.mdpi.com/2072-6694/2/3/1379
- Lightdale CJ. Esophageal cancer. Official journal of the American College of Gastroenterology | ACG [Internet]. 1999 Jan [cited 2023 Mar 31];94(1):20. Available from: https://journals.lww.com/ajg/citation/1999/01000/esophageal_cancer.1.aspx
- Hanahan D, Weinberg RA. The hallmarks of cancer. Cell [Internet]. 2000 Jan 7 [cited 2023 Mar 31];100(1):57–70. Available from: https://www.cell.com/cell/abstract/S0092-8674(00)81683-9
- Zhang Y. Epidemiology of esophageal cancer. World J Gastroenterol [Internet]. 2013 Sep 14 [cited 2023 Mar 31];19(34):5598–606. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3769895/
- Abbas G, Krasna M. Overview of esophageal cancer. Ann Cardiothorac Surg [Internet]. 2017 Mar [cited 2023 Mar 31];6(2):131–6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5387155/
- Rosen RD, Sapra A. Tnm classification. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Mar 31]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK553187/
- Besharat S, Jabbari A, Semnani S, Keshtkar A, Marjani J. Inoperable esophageal cancer and outcome of palliative care. World J Gastroenterol [Internet]. 2008 Jun 21 [cited 2023 Mar 31];14(23):3725–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719235/