Esophageal cancer

Facts

In the last decade, major strides have been made in the early diagnosis and treatment of esophageal cancer.

Seattle Cancer Care Alliance (SCCA) offers comprehensive treatment for this disease from a team of experts.

What is esophageal cancer?

Upper digestive systemEsophageal cancer occurs when cells in the esophagus begin to grow abnormally.

They do not respond to regular cell growth, division and death signals like they are supposed to. They also don’t organize normally. 

Instead they grow into a tumor, which may extend into the open space inside your esophagus or break through underlying layers of your esophageal wall. 

About 17,000 people are diagnosed with esophageal cancer in the United States each year. 

Understanding your esophagus

EsophagusYour esophagus is a 10-inch long, hollow, muscular tube that connects your throat to your stomach. The wall of your esophagus has several layers of tissue that work together to push food down into your stomach when you swallow.

  • Thin, flat squamous cells line the inside of most of your esophagus. Closer to your stomach, the lining is made up of glandular epithelial cells.
  • Under the lining are submucosal tissues, which keep your esophagus moist.
  • Thick muscles under the submucosal tissues contract in waves to push food down your esophagus.
  • Connective tissue forms the outer covering of your esophagus.

Types

Usually esophageal cancer starts in the squamous cells or glandular epithelial cells that line the esophagus. From there, cancer may spread into the esophageal wall and to nearby lymph nodes or other tissues or organs.

  • Adenocarcinoma — starts in the glandular epithelial cells, usually near the bottom of the esophagus, where the esophagus meets the stomach. Often these tumors arise in people with Barrett’s esophagus.
  • Squamous cell carcinoma — starts in squamous cells anywhere in the esophagus, most often in the upper and middle esophagus.

In the U.S., adenocarcinoma is more common than squamous cell carcinoma in the esophagus. The reverse is true in the rest of the world. 

  • As the rates of gastroesophageal reflux disease (GERD) and obesity have risen in the U.S., so has the rate of adenocarcinoma. 
  • As the use of cigarettes and tobacco has dropped, the rate of squamous cell cancer has dropped as well. 

Symptoms

Esophageal cancer can be difficult to detect early on because it may not cause noticeable symptoms until a tumor gets big enough to interfere with swallowing. 

See your doctor if you:

  • Have trouble swallowing
  • Have pain with swallowing
  • Frequently choke on food

Difficulty swallowing may start with foods like meat, bread or raw vegetables, but as a tumor grows, even liquids may be painful to swallow.

Other early warning signs may result from a variety of medical issues. See your doctor if you experience any of these other potential signs for a prolonged period:

  • Pressure or burning in your chest
  • Indigestion or heartburn
  • Unexplained weight loss
  • Pain behind your breastbone or in your throat

Diagnosing 

After your doctor has given you a thorough exam, you may need several tests to help diagnose esophageal cancer.

Flexible endoscopy

Endoscopy, including endoscopic ultrasound, gives the best information about the structure of your esophagus. It shows complications of reflux, such as esophagitis (irritation of the esophagus), and tissues that may have cancer. For this test:

  • You are sedated (given medicine to make you sleepy and relaxed). 
  • The doctor inserts a thin, flexible tube (endoscope) into your mouth or nose and down into your esophagus. 
  • The endoscope has a light and a tiny camera on the end to take close-up images, which show on a video monitor in the exam room.
  • The doctor can use instruments to take a tissue sample (biopsy) so a pathologist can check the cells under a microscope for cancer. 

If you have a small, early-stage cancer that has not gone deeper than the lining of your esophagus, your doctor may be able to remove all of it during your endoscopy (endoscopic mucosal resection). 

Imaging studies

If your doctor finds cancer or believes you may have cancer, you will likely have imaging tests to better understand your cancer and tell whether it has spread beyond your esophagus. These may include a computed tomography (CT) scan or positron emission tomography (PET) scan.

Blood tests

Your doctor may ask you to have a complete blood count to check the level of each type of blood cell in your bloodstream. Low red blood cells (anemia) may be a sign of internal bleeding, which sometimes happens with esophageal cancer (as well as other conditions).

Stages 

The treatment that your doctors recommend for esophageal cancer will be based in part on the stage of your cancer. The stage depends on:

  • How far the cancer has spread through the wall of your esophagus
  • Whether the cancer has spread to nearby lymph nodes
  • Whether the cancer has spread to other parts of your body

There are different staging systems for adenocarcinoma and squamous cell carcinoma of the esophagus. Both systems use Roman numerals I, II, III and IV, with stage I being the least advanced and stage IV being the most advanced stage.

What causes esophageal cancer?

Doctors don’t know the precise causes of esophageal cancer, but studies have identified several risk factors.

SCCA’s Gastrointestinal Cancer Prevention Program offers a personalized approach to risk assessment, screening and prevention for people at high risk for esophageal cancer and other gastrointestinal cancers. 

Risk factors

These factors may affect your risk for esophageal cancer:

  • Sex — Men are nearly three times more likely than women to develop esophageal cancer.
  • Race — The disease is three times more common among African-Americans than European Americans.
  • Age — The rate of esophageal cancer rises after age 50.
  • Tobacco and alcohol — These increase the risk of developing cancer, especially squamous cell carcinoma.
  • Weight — Obesity is linked with adenocarcinoma because it is linked with GERD, which can damage the esophagus.
  • Head or neck cancers — These increase esophageal cancer risk.
  • Human papillomavirus (HPV) — People who are infected with HPV are at greater risk.
  • Injury to the esophagus — This can cause scarring and damage cells in the area and is linked with higher esophageal cancer risk.
Barrett's esophagus

When acid from the stomach repeatedly comes up into the esophagus — as it does in GERD — the acid may damage the cells of the esophageal lining. Over time this damage can cause the cells to mutate and become more like cells in the stomach and intestine, leading to a condition called Barrett’s esophagus.

In a small fraction of people, the mutated cells turn into cancer (esophageal adenocarcinoma).

Several options, including lifestyle changes, medication, radiofrequency ablation and surgery, are available to control reflux and to prevent or treat the problems that can develop as a result of reflux. 

Read more about Barrett’s esophagus and treatment options for this condition at the UW Medicine Center for Esophageal & Gastric Surgery.
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