The esophagus connects the throat to the stomach, and is considered part of the digestive system. Esophageal cancer can form anywhere along the length of the esophagus, usually in the innermost cells that line its walls.
Esophageal cancers make up about 1% of new cancer diagnoses in the United States, though it’s much more common in other parts of the world. It’s nearly three and a half times more common in men than in women. The median age at diagnosis is 68, with nearly 90% of diagnoses occurring after the age of 55.
Early esophageal cancers rarely cause symptoms, and are therefore rarely found. As the disease progresses, it may cause:[1]
Chest pain or discomfort
Difficulty swallowing, or a sense of food stuck in the throat
Vomiting
Unexplained weight loss
Hoarseness
Bleeding into the esophagus (this may turn stool black or cause anemia)
Chronic cough
Bone pain (if the cancer has spread to the bones)
These symptoms may be caused by any number of health conditions, and should be evaluated by a medical professional.
Esophageal cancer usually presents as one of two subtypes, each characterized by distinct features and biological behaviors:
Squamous cell carcinoma: Squamous cells line the innermost layer of the esophagus (known as the mucosa). This type of cancer can occur anywhere in the esophagus, but most often forms in the neck or upper portion of the chest cavity. This form of esophageal cancer used to be the most common, but now accounts for less than 30% of all diagnoses in the US.
Adenocarcinoma: Adenocarcinomas form in the gland cells that produce mucus, and are usually found in the lower third of the esophagus. These can also form in the gastroesophageal (GE) junction (where the esophagus connects to the stomach). GE junction cancers usually behave like other adenocarcinomas of the esophagus, and generally follow the same treatment plan.
Rare forms of esophageal cancer: Lymphomas, melanomas, and sarcomas can all originate in the esophagus, but these are very rare.
Survival Rates and Incidence
Esophageal cancer survival rates are based on how far it has spread:
Localized: There is no sign the cancer has spread outside the esophagus.
Regional: The cancer has spread to nearby structures or lymph nodes
Distant: The cancer has spread to distant parts of the body.
The 5-year survival rate for each stage is shown below:
Below is the overall incidence of esophageal cancer by age group:
Risk Factors
There are several confirmed risk factors that contribute to an individual’s risk for esophageal cancer:[3]
Biological sex: Men are nearly 3.5 times more likely to develop esophageal cancer than women. For people assigned male at birth, the overall lifetime risk of developing esophageal cancer is about 1 in 127, whereas for people assigned female at birth, that risk decreases significantly, to 1 in 434.
Smoking & secondhand smoke exposure: Smoking and secondhand smoke increases your risk of many cancers, and contributes significantly to esophageal cancer risk. A pack-a-day smoker has at least double the risk of a nonsmoker. Tobacco smoke contains numerous carcinogens that can lead to genetic mutations and uncontrolled cell growth, ultimately resulting in cancer. Quitting smoking at any age can significantly reduce the risk of cancer and other smoking-related diseases. The body begins to repair itself almost immediately after quitting, with the risk of cancer decreasing over time. Even individuals who have smoked for many years can benefit from quitting, as the risk decreases with each year of abstinence.
Alcohol use: Alcohol has been shown to increase the risk of esophageal cancer. The risk increases the more that one drinks, and is significantly compounded if one both consumes alcohol and smokes.
Gallbladder removed: Removal of the gallbladder has been shown to increase the risk of esophageal cancer, likely due to increased reflux[2] affecting the tissues of the esophagus.
Red and processed meat consumption: Diets high in red and processed meats have been tied to higher rates of esophageal cancer, though more studies are needed to understand this connection. In general, diets lower in salt, processed meat, and red meat are correlated to lower risk for multiple types of cancer.
Health conditions: some text
Achalasia: This condition prevents the lower esophageal sphincter from properly relaxing, leading food and liquid to collect in the lower esophagus. This extended exposure leads the lower portion of the esophagus to stretch and become irritated over time. Achalasia significantly increases one’s risk for esophageal cancer, which tends to develop about 15-20 years after the condition began.
Gastroesophageal reflux disease (GERD): This chronic form of acid reflux is known to increase the risk of stomach and esophageal cancers.
Barrett’s esophagus: Barrett’s esophagus is a condition caused by acid reflux, in which the cells lining the esophagus become inflamed and the lining thickens. Usually the result of longterm GERD, Barrett’s esophagus may or may not cause noticeable symptoms.
Chronic hepatitis B: Multiple studies have shown that chronic hepatitis B (HBV) infection increases the risk of several gastrointestinal cancers, including esophageal.
Tylosis: This rare genetic condition leads to a cluster of symptoms, including papillomas (small growths) in the esophagus. Individuals with this syndrome have a very high risk of developing esophageal cancer, and should monitor their health closely.
Plummer-Vinson syndrome: This rare syndrome leads to webbing in the upper esophagus, along with several other symptoms. This webbing can lead to food becoming trapped in the esophagus, which may result in chronic inflammation. Approximately 10% of people with Plummer-Vinson syndrome go on to develop esophageal cancer.
HPVinfection: HPV viruses have been linked to multiple cancers, including esophageal. This cause appears to be rare in the US but much more common in other parts of the world.
Protective Factors
Several factors have been shown to have protective effects against esophageal cancer:
Maintaining a healthy weight: Numerous studies have linked higher BMI to increased risk of various types of cancer, including esophageal cancer. Excess body fat can lead to higher levels of estrogen and insulin, as well as increased production of insulin-like growth factors. Higher BMI is also associated with chronic low-level inflammation, which can cause DNA damage over time and contribute to the development of cancer. Maintaining a healthy weight helps you to avoid these risks.
Physical activity: Regular exercise can reduce your risk of several types of cancer through a combination of physiological, hormonal, and immunological changes. It can reduce inflammation, improve immune function, improve hormonal regulation, and lower insulin levels. The American Cancer Society recommends engaging in at least 150 minutes of moderate activity or 75 minutes of vigorous activity each week. Furthermore, data indicates that individuals can see significant incremental benefit with additional exercise.
Allow beverages to cool before drinking: Frequent consumption of very hot liquids may damage the cells that line the esophagus. Injury to the esophagus can lead to more frequent cell turnover or scarring, both of which might eventually result in cell mutations that cause cancer.
Vegetable consumption: Vegetables are rich in various nutrients which have been shown to have protective effects against multiple cancers, including esophageal. These foods contain a variety of antioxidants, which help neutralize free radicals in the body and reduce inflammation. Citrus fruits in particular seem to reduce the risk of stomach cancer.
Aspirin: Several studies have shown an association between daily aspirin use and a reduced risk for several types of cancer, including esophageal. The exact mechanisms by which aspirin may reduce cancer risk are not fully understood but may involve its anti-inflammatory and antiplatelet effects. Aspirin inhibits the production of prostaglandins, which are involved in inflammation and tumor growth, and it also reduces the aggregation of platelets, which may play a role in the spread of cancer. While daily aspirin use may offer benefits in reducing cancer risk, it is not without potential risks. Aspirin can increase the risk of gastrointestinal bleeding and other bleeding-related complications, particularly in older adults or those with a history of gastrointestinal ulcers or bleeding disorders.
NSAIDS: Nonsteroidal anti-inflammatory drugs (NSAIDs) are a class of medications commonly used to relieve pain, reduce inflammation, and lower fever, and they have also been shown to reduce esophageal cancer risk with regular use. In addition to their anti-inflammatory properties, NSAIDs have been shown to inhibit cell proliferation, induce programmed cell death, suppress tumor growth, and modulate immune responses. While NSAIDs have been associated with potential benefits in cancer prevention, their use is not without risks. Long-term or high-dose NSAID use has been linked to gastrointestinal bleeding, ulcers, and perforation. Additionally, certain NSAIDs have been associated with an increased risk of cardiovascular events such as heart attack and stroke.
Blood type O: Individuals with blood type O have a lower risk of esophageal cancer compared to other blood types.
Screening
Early detection of esophageal cancer has a dramatic impact on prognosis. The 5-year survival rate for localized cancer is 48.1%, but drops to just 5.3% once the cancer has spread to distant parts of the body.
Depending on your age and risk factors, the optimal esophageal cancer screening will vary:
Medical history / physical exam: A thorough medical history and physical examination is often the best first test for possible esophageal cancer. Knowing your family history and evaluating any new or ongoing symptoms may lead your doctor to order further tests or refer you to a gastroenterologist.
Endoscopy: During this test, a doctor passes a thin, flexible camera down the esophagus to examine the organ, with or without the aid of ultrasound equipment. If anything abnormal is seen, a tissue sample can be taken for biopsy via the endoscope. This test can be used to diagnose esophageal cancer, as well as to determine its spread.
Barium swallow: This test can show any changes to the usually-smooth lining of the esophagus, and may be ordered if you’re having difficulty swallowing. During this test you’ll swallow a chalky barium solution which will coat the esophagus. When x-rays are taken, the barium will show clear outlines of the esophagus, as well as any anomalies. This test can detect even small, very early cancers.
Complete blood count (CBC): This test determines the values of different types of cells in the blood. Anemia (a low red blood cell count) may occur with esophageal cancer, as tumors may cause bleeding, though usually this finding in a CBC would have a different cause.
Imaging tests: CT scans, x-rays, positron emission tomography (PET) scans, and MRIs can all be used to look for esophageal cancer, or to determine the extent to which the cancer has spread.
Liquid biopsy: Liquid biopsy is an investigational cancer-detection technique which looks for DNA fragments in the blood to determine whether cancer is present. Though still in its infancy, this technology is promising, particularly in screening for hard-to-detect cancers or cancers whose symptoms are minimal or tend to appear only after they’ve spread. Esophageal cancer is one of many cancers which can be screened for via this method.
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