Esophageal Cancer

What causes esophageal cancer is still somewhat unknown. Researchers believe one possibility is that irritation to the esophagus eventually damages the cells that line it, and the cells become cancerous. Several factors are known to increase the risk of developing esophageal cancer.

In the United States, the most common esophageal cancer risk factors include:

Age

Esophageal cancer risk increases with age. Most people are diagnosed after age 55.

Gender

Men are four times more likely than women to develop cancer of the esophagus.

Tobacco and alcohol use

Of all the risk factors you can control, these two are the most important. Used alone, tobacco and alcohol each significantly increase the risk; using both raises it even more.

Gastroesophageal reflux disease (GERD)

GERD happens when digestive acids from the stomach flow back into the lower esophagus. Often simply called reflux, GERD sometimes causes symptoms such as heartburn, and may slightly raise the risk of adenocarcinoma. But most people with GERD do not develop esophagus cancer.

Barrett’s esophagus

Long-term reflux can damage the lining of the esophagus and lead to changes in the cells. The squamous cells that line the esophagus are replaced with gland cells, which are more resistant to stomach acid. This condition, called Barrett’s esophagus, raises the risk of adenocarcinoma. Over time, the gland cells may become pre-cancerous, a condition called dysplasia.

Obesity

Being overweight or obese increases the risk of esophageal cancer, in part because it raises the likelihood of GERD.

Drinking very hot liquids

Frequently drinking liquids at temperatures of 149° F or 65° C (much hotter than a typical cup of coffee) may increase squamous cell esophageal cancer risk.

Achalasia

This condition occurs when the muscle at the lower end of the esophagus doesn’t relax properly, causing food and liquid to collect there. Over time, this can irritate the cells lining the lower esophagus. Achalasia can significantly raise the risk of esophageal cancer.

Family history and inherited conditions do not seem to be risk factors for esophageal cancer.

Having any of these risk factors doesn’t mean you’ll develop esophageal cancer, and many people with esophageal cancer have no risk factors. Talk to your doctor about your risk and whether you should be tested.

Like most cancers, esophageal cancer treatment is most successful when cancer is detected early. However, routine esophageal cancer screening is not recommended unless you have an increased risk of the disease.

If you do have risk factors, such as Barrett’s esophagus, talk with your doctor about having an upper endoscopy screening. This test lets your doctor examine the inside of your esophagus using a lighted tube placed down your throat and into your esophagus. Your doctor also may remove small samples of tissue to have them checked for precancerous cells (dysplasia).

Esophageal cancer cannot be fully prevented, and some risk factors like age, gender and race can’t be changed. But you may be able to help prevent it by taking steps to reduce controllable risk factors. For example, in the United States, the most important lifestyle risk factors for esophageal cancer are the use of tobacco and alcohol.

Other preventive measures include:

• Avoid tobacco and alcohol use
• Eat a diet rich in fruits and vegetables
• Maintain a healthy weight
• Be physically active on a regular basis
• If you have GERD or Barrett’s esophagus, follow through with treatment

Esophageal cancer is often diagnosed at an advanced stage because there are no early signs or symptoms. Scripps cancer specialists are experts in diagnosing and staging esophageal cancer to determine the best course of treatment. In addition to a medical history and physical exam, Scripps doctors may use the following tests for an esophageal cancer diagnosis.

Barium swallow

Barium swallow is a type of X-ray that can show any abnormal areas on the lining of the esophagus. Before the X-ray is taken, you’ll drink a thick, chalky liquid called barium, which coats the walls of the esophagus so they will be clearly visible on the X-ray. Barium swallow can often detect cancer at an early stage.

Esophagoscopy

Esophagoscopy or upper endoscopy is a procedure in which an endoscope — a hollow tube with a camera lens — is placed down the throat into the esophagus to examine the lining of the esophagus. If very small tumors are found, they may removed during this procedure.

Computed tomography (CT) scan

A CT scan is a form of X-ray imaging that captures images of the body from different angles. The images are combined to create detailed cross-sectional views of organs, bones and blood vessels.

Positron emission tomography (PET) scan

A PET scan uses a glucose that contains a radioactive substance (called a tracer) to look for cancer. A PET scan is combined with a CT scan.

Biopsy

Biopsy is the collection of a small part of the suspicious tissue for testing and further examination in the lab by a pathologist.

The later the stage of esophageal cancer, the more advanced the cancer is. Late-stage cancers are generally more challenging to treat. Several factors help doctors determine the esophageal cancer stage, including how far the cancer has grown into the wall of the esophagus and if it has spread to lymph nodes, nearby structures or distant parts of the body.

Staging for esophagus cancer also includes a tumor grade, which describes how much the cancer looks like normal tissue. The higher the grade, the more abnormal the cancer cells appear. Unfortunately, many cancers of the esophagus are not diagnosed until they have reached advanced stages.

Squamous cell carcinoma and adenocarcinoma have different stage groupings. If a person has both squamous cell cancer and adenocarcinoma, their cancer is staged the same as squamous cell carcinoma.

Squamous cell carcinoma stages

Staging for squamous cell cancer also includes the location of the tumor along the esophagus, and a tumor grade, which describes how much the cancer looks like normal tissue. The higher the grade, the more abnormal the cancer cells appear and the faster they spread.

Stage 0

This is the earliest stage of esophageal cancer, also called high-grade dysplasia. Cancer cells are found only in the layer of cells lining the esophagus. The tumor is low-grade and can be anywhere on the esophagus.

Stage IA

Cancer has grown into the layers of the lining of the esophagus, but has not spread. The tumor is low-grade and can be anywhere on the esophagus.

Stage IB

Cancer has grown:

• Into the layers of the lining of the esophagus and has not spread, but the tumor is mid-grade and anywhere on the esophagus.
• Into or through the muscle layer, but the tumor is low-grade and anywhere on the esophagus.

Stage IIA

Cancer has grown into the muscle layer, or through it into the connective tissue covering the outside of the esophagus. The tumor is low-grade and located in the middle to upper part of the esophagus, or higher-grade and in the lower esophagus.

Stage IIB

Cancer has grown:

• Into the muscle layer, or through it into the connective tissue covering the outside of the esophagus. The tumor is higher-grade and located in the middle to upper part of the esophagus.
• Into the muscle layer but not to the outer layer of tissue covering the esophagus, and to one or two nearby lymph nodes. The tumor can be any grade and anywhere on the esophagus.

Stage IIIA

Cancer that has grown:

• Into the muscle layer but not to the outer layer of tissue covering the esophagus, and has spread to three to six nearby lymph nodes. The tumor can be any grade and anywhere on the esophagus. 
• Through the wall of the esophagus to its outer layer and has spread to one or two nearby lymph nodes. The tumor can be any grade and anywhere on the esophagus. 
• All the way through the esophagus and into nearby organs or tissues, but still can be removed with surgery. It has not spread to nearby lymph nodes or distant parts of the body. The tumor can be any grade and anywhere on the esophagus. 

Stage IIIB

Cancer has grown through the wall of the esophagus to its outer layer, and has spread to three to six nearby lymph nodes. The tumor can be any grade and anywhere on the esophagus. 

Stage IIIC

Cancer has:

• Grown all the way through the esophagus and into nearby organs or tissues, but still can be removed with surgery. It has spread to one to six nearby lymph nodes. The tumor can be any grade and anywhere on the esophagus.
• Grown into the trachea (windpipe), aorta (the large blood vessel coming from the heart), spine or other important structures and cannot be removed with surgery. It may or may not have spread to nearby lymph nodes, but has not spread to distant lymph nodes or parts of the body. The tumor can be any grade and anywhere on the esophagus.
• Spread to seven or more nearby lymph nodes, but not to distant lymph nodes or body parts. The tumor can be any grade and anywhere on the esophagus. 

Stage IV

Cancer has spread to distant lymph nodes or other sites. It can be any grade and can be anywhere on the esophagus.

Adenocarcinoma stages

The location of the cancer on the esophagus does not affect adenocarcinomas staging.

Stage 0

This is the earliest stage of esophageal cancer, also called high-grade dysplasia. Cancer cells are found only in the layer of cells lining the esophagus, and the tumor is low-grade.

Stage IA

Cancer has grown into the layers of the lining of the esophagus, but has not spread. The tumor is low or mid-grade.

Stage IB

Cancer has grown:

• Into the layers of the lining of the esophagus, but has not spread. The tumor is high-grade.
• Into the muscle layer of the esophagus and is low to mid-grade.

Stage IIA

Cancer has grown into the muscle layer, but has not spread and is high-grade.

Stage IIB

Cancer has grown:

• Through the wall of the esophagus to its outer layer and is any grade.
• Into the layers of the esophageal wall, may have grown into the muscle wall and has spread to one or two nearby lymph nodes. It can be any grade.

Stage IIIA

Cancer has grown:

• Into the layers of the esophageal wall, may have grown into the muscle wall and has spread to three to six nearby lymph nodes. It can be any grade.
• Through the wall of the esophagus to its outer layer and has spread to one or two nearby lymph nodes It can be any grade.
• All the way through the esophagus and into nearby organs or tissues, but still can be removed with surgery. It has not spread to lymph nodes or distant sites. It can be any grade.

Stage IIIB

Cancer has grown through the wall of the esophagus to its outer layer, and spread to three to six nearby lymph nodes. It can be any grade.

Stage IIIC

Cancer has:

• Grown all the way through the esophagus and into nearby organs or tissues, but still can be removed with surgery. It has spread to one to six nearby lymph nodes. It can be any grade.
• Has grown into the trachea (windpipe), aorta (the large blood vessel coming from the heart), spine or other important structures and cannot be removed with surgery. It may or may not have spread to nearby lymph nodes and can be any grade.
• Spread to seven or more nearby lymph nodes, but not to distant lymph nodes or body sites. It can be any grade.

Stage IV

Cancer has spread to distant lymph nodes or other sites. It can be any grade.

Resectable and unresectable esophageal cancer

While staging provides information about the severity of esophageal cancer, it doesn’t indicate how the cancer should be treated. Doctors generally need to know whether the tumor can be removed with surgery (resectable) and may describe esophageal cancer as resectable or unresectable.

• Resectable esophageal cancer is when the cancer can potentially be completely removed during surgery.
• Unresectable esophageal cancer is when the cancer cannot be completely removed with surgery. The tumors may have spread too far, or surgery is not possible due to the location of the tumor or the patient’s health.

In general, all stage 0, I and II esophageal cancers are potentially resectable. Most stage III cancers also are potentially resectable, even when they have spread to nearby lymph nodes, as long as the cancer has not grown into nearby structures or major blood vessels.

Esophageal cancer that has spread into nearby structures, major blood vessels or distant parts of the body are considered unresectable, and usually are best treated with non-surgical options.

No one wants to hear that they have cancer. You may feel frightened, overwhelmed, anxious or sad. All of these feelings are perfectly normal. The more you learn about your diagnosis and next steps, the sooner you can begin to make informed decisions about your treatment.

Questions and considerations

Here are some questions you may want to ask your doctor or health insurance provider regarding your liver cancer diagnosis:

• Should I get a second opinion?
• How do I find a specialist?
• What is my cancer treatment plan?
• Will I have to miss work/school?
• What are the side effects of esophageal cancer treatment?
• How successful is my treatment likely to be?
• What costs will be covered by insurance?
• Which costs will I be responsible for?

Your Scripps cancer care team is here to help you find the answers you need to take an active role in your care. In addition, there are a number of community resources that provide education, information and helpful resources — often at no cost.

Learn more about the many cancer patient resources available to you and your loved ones at Scripps.

Esophageal cancer treatment plans depend on the type and stage of the cancer and whether it can be surgically removed. The patient’s age and overall health also affect treatment options.

Scripps doctors may be able to remove small, early-stage tumors on the esophagus while performing an esophagoscopy, which does not require surgery.

If surgery is needed, Scripps uses both open and minimally invasive surgical techniques to remove esophageal cancer. If cancer cannot be completely removed by surgery, or the patient cannot have surgery, radiation therapy with chemotherapy can be offered as curative treatment. Most often, radiation and chemotherapy is provided together prior to surgery to help shrink the tumor.

Esophageal cancer surgery

The two types of esophageal cancer surgery offered by Scripps include the following:

• Esophagectomy is when Scripps surgeons remove part of the esophagus and nearby lymph nodes and reattach the remaining esophagus to the stomach. Whenever possible, our surgeons may perform this surgery using minimally invasive techniques.
• Esophagogastrectomy is when surgeons remove the upper portion of the stomach, depending on how far the cancer has spread, in addition to part of the esophagus and nearby lymph nodes.

Radiation therapy for esophageal cancer

Scripps has the most comprehensive radiation therapy offerings in San Diego for esophageal cancers, including highly targeted radiation therapy technologies that treat cancerous cells while protecting surrounding tissues and organs from excess radiation damage.

Chemotherapy and chemoradiotherapy

Chemotherapy is often combined with radiation therapy for treatment of esophageal cancer before a surgery or when a patient is not a candidate for surgery. Combining chemotherapy and radiation therapy is known as chemoradiotherapy.

Some esophageal cancer treatment plans involve clinical trials. Talk with your physician about whether a clinical trial is right for you. 

See a list of clinical trials currently enrolling patients.

Your Scripps cancer team will develop a customized treatment plan outlining the treatments and therapies we recommend for your care. Before you begin treatment, you and your physician will review your plan together and discuss any questions or concerns you may have.

Your esophageal cancer treatment plan generally includes:

• Family and medical history
• A summary of your cancer diagnosis and staging information
• Diagnostic testing completed (e.g., imaging, biopsy, lab tests)
• Plans for surgery, radiation, chemotherapy and/or other treatments
• Potential side effects of treatments
• Contact information for your cancer care team members

Along with helping you understand your course of treatment and encouraging discussion between you and your physician, your plan helps your team coordinate your care. You also can share your treatment plan with other providers who may be involved in your medical care.

Your esophageal cancer care team includes health and medical professionals from a wide range of specialties. Scripps will customize your team to ensure you have the expertise and support you need. 

Your team may include:

• Gastroenterologists
• Surgeons and surgical oncologists
• Radiation oncologists
• Medical oncologists
• Registered nurses
• Nurse navigators
• Dietitians
• Oncology social workers

Visit your cancer care team for more information on Scripps' multi-disciplinary approach to treatment.

Patient education is an integral part of understanding and coping with your cancer diagnosis and treatment. To stay informed, we encourage our patients, along with their caregivers and family members, to:

• Bookmark the Scripps glossary of cancer terms for easy referencing.
• Download the appointment form and list of medications form on our resources page.
• Consult your oncology team for educational materials and a list of trusted online sources beyond the Scripps site. 

Navigating cancer might seem overwhelming — especially with so much information online. To ensure you receive the most accurate details, always look to your multidisciplinary team of cancer care experts first.