Esophageal Cancer

What Is Esophageal Cancer?

Esophageal cancer starts in the lining of the esophagus. This is the tube that carries food from your throat to your stomach. There are more than 22,000 Americans diagnosed with this cancer every year. It’s important to know your risk and to watch for symptoms. 

Types of Esophageal Cancer

• Esophageal adenocarcinoma: This is the most common type of esophageal cancer in the U.S. It starts in the cells where the esophagus connects to the stomach. These cells make mucus. The mucus makes it easier for food to pass down the esophagus to the stomach.
• Esophageal squamous cell carcinoma (ESCC):This type is the most common in the world.  Less than one-third of esophageal cancers in the U.S. are ESCC. This type starts in the lining of the upper part of esophagus. The squamous cells line the esophagus. They also protect it from being scratched or damaged. If these cells are damaged over and over again, they can change. After years of damage, these cells may turn cancerous. Although it is not well understood, the human papillomavirus or HPV, increases the risk of esophageal squamous cell cancer by about 22%. This article helps explain the connection between HPV and ESCC. 

Causes of Esophageal Cancer

Esophageal cancer does not have a single known cause. Certain risk factors can increase your chances of developing it. 

Risk Factors

• Acid reflux/GERD
• Achalasia
• Barrett’s esophagus
• Being male
• Being overweight
• Certain inherited conditions
• Drinking alcohol
• Exposure to chemicals
• Genetics
• HPV
• Older age
• Using tobacco

Genetics

Genetics can play a role in esophageal cancer.  Some people are born with genes that raise their risk. Other gene changes happen over time because of things in the environment. 

Inherited gene changes: Some people are born with genetic mutations that have been passed down by their parents

Acquired gene changes: Genetic changes that happen over a person’s life can come from smoking, drinking alcohol, acid reflux and exposure to certain chemicals. Many of the risk factors listed in the bullets above can damage the DNA of the cells in the esophagus. Changes to DNA will affect how genes work. If certain genes don’t function the way they should, cells can grow too much and cancer may develop.

Family patterns: Esophageal cancer can run in families. Shared genes and habits like smoking and poor diet can lead to this cancer.

Prevention  

Screening for esophageal cancer can detect changes early. Identifying cancer before symptoms appear is when cancer is easier to treat. Early cancer detection saves lives.

Regular routine screening is recommended for people who are considered at high risk due to: 

• Barrett’s esophagus
• Chronic acid reflux or GERD
• Family history of esophageal cancer

This screening can be done by upper endoscopy. During the screening, a thin, flexible tube (an endoscope) is passed down the throat. This tube has a camera so the doctor can look at the lining of the esophagus. It also allows the doctor to take tissue samples to check for abnormal cells.

Lower Your Risk

Esophageal cancer can’t always be avoided. Follow these preventive measures to help lower your risk.

• Lose weight: Obesity raises the risk of esophageal adenocarcinoma.
• Do not smoke or drink alcohol. These habits greatly increase the risk for esophageal squamous cell cancer. 
• Treat and manage acid reflux. Follow your doctor’s treatment plan for GERD and Barrett’s esophagus. 
• Maintain a healthy weight.
• Eat a healthy and balanced diet.
• Stay physically active. 

Signs and Symptoms

Early esophageal cancer may have few or no symptoms. As it grows, symptoms become more noticeable. Symptoms of esophageal cancer may include:

• Anemia (low levels of red blood cells)
• Black stools
• Constant cough
• Chronic hiccups
• Difficulty swallowing – the most common symptom
• Heartburn
• Hoarseness
• Indigestion
• Low appetite
• Pain or burning feeling in the throat or chest
• Pain while swallowing
• Pneumonia
• Regurgitating food from the esophagus
• Unintended weight loss
• Vomiting

See a gastroenterologist if you are experiencing these symptoms. 

Diagnosis

A physical exam, review of your medical history and testing will be done to confirm esophageal cancer. 

Imaging Tests

Barium swallow test: This may be the first test if you’re having trouble swallowing. You will swallow a chalky liquid called barium sulfate to coat the inner walls of the esophagus. The x-rays are taken. It can show abnormal areas in the esophagus, including early cancers.

Computed tomography (CT) scan: This form of imaging uses x-rays to take detailed cross-sectioned images of the body. A CT scan may be used if esophageal cancer has spread to other organs. A CT scan also may be used to guide a biopsy needle to a specific area to get a tissue sample.

Positron emission tomography (PET) scan: This test uses a slightly radioactive liquid injected into the blood. It collects in cancer cells, and the areas of radioactivity can be seen on a PET scan. PET scan images aren’t as detailed as other forms of imaging, but they can show areas of cancer anywhere in the body. A PET scan may be combined with a CT if your doctor thinks the cancer may have spread.

Lab Tests

Blood tests: These tests may be used to measure different types of cells in the blood. With esophageal cancer, a blood test can show if you have anemia from a bleeding tumor.

Diagnostic Procedures

Upper Endoscopy: This test is the most common way to diagnose esophageal cancer. An upper endoscopy is done when there are  unexplained symptoms. It is also done for patients with Barrett’s esophagus, long-term GERD or family history of esophageal cancer. An endoscope is a flexible tube with a tiny camera and light at the end. It is used to look inside the body. A biopsy is often performed during an endoscopy and checked in a  lab for cancer. 

Endoscopic Ultrasound: This test can be used to stage esophageal cancer. People who may need an endoscopic ultrasound are those with cancer that is only in the esophagus. An endoscopic ultrasound uses a thin, flexible tube with a tiny camera, light and ultrasound probe. During the procedure, a small needle may be used to take tissue samples. These samples are sent to the lab to check for cancer. 

Esophageal Cancer Staging

Staging refers to how advanced esophageal cancer is and if it has spread. The TNM system is used to identify the stage of the cancer.

• T: How deep in the esophagus the primary tumor is and how far it has spread.
• N: Whether cancer has spread to the nearby lymph nodes.
• M: Whether cancer has metastasized, which is when it spreads to distant organs and lymph nodes.

The stage of esophageal cancer is based on the TMN information. Cancer stages range from  0 (pre-cancer) to stage IV (advanced cancer). Oncologists look at the type of cancer cells, how fast it is growing and there the tumor is located.

Stage 0: Abnormal cells are present but have not formed a tumor.

Stage 1: A tumor is present in the esophagus, but it has not spread to lymph nodes or distant organs.

Stage 2: The cancer has grown deeper into the muscle tissue of the esophageal wall and may have spread to one or two nearby lymph nodes.

Stage 3: The cancer has spread to tissues outside the esophagus and to several nearby lymph nodes.

Stage 4: The cancer has spread to distant lymph nodes and/or distant organs such as the liver, lungs or bones. 

Treatment

Your treatment plan will depend on your type of esophageal cancer. The stage of the cancer and your overall health play a role in treatment selection. Your care team will work together to create a treatment that offers the best chance of getting rid of the cancer while limiting side effects. Different treatment options are often combined. Very early cancers may be removed with surgery. Other options include medications, procedures and changing lifestyle. Treatment is individualized based on your overall health and goals.

Medications

• Chemotherapy: Kills fast-growing cells. It may be used to treat esophageal cancer before or after surgery.
• Immunotherapy: Uses your immune system to attack tumors. This treatment is most often used for advanced esophageal cancer.
• Targeted therapy: Stops or slows the cancer cells from growing and spreading. This medication may be given by capsules or IV infusion.

Procedures

Endoscopic treatments: Earlier stages of esophageal cancer may be treated with differently. Endoscopic procedures can remove cancer that is only on the surface of the esophagus. Endoscopic mucosal resection (EMR) removes small early cancer. Endoscopic submucosal dissection (ESD) removes larger or deeper cancer from the esophagus lining. Radiofrequency ablation (RFA) uses heat energy to destroy precancerous cells. Cryotherapy uses extreme cold to freeze and destroy precancerous cells. Photodynamic therapy (PDT) uses a special medicine and light to kill cancer cells. These treatments are less invasive than surgery.

Radiation therapy: High-energy photon beams are used to kill cancer cells. Newer methods help doctors aim the treatment more precisely at the cancer. This treatment is often used with chemotherapy or surgery.

Surgery: Esophagectomy is the most common treatment for esophageal cancer. This surgery removes all or part of the esophagus, stomach and lymph nodes. Your doctor will recommend the best surgical technique for you based on the location of the tumor and if the cancer has spread.

Lifestyle Management

Maintaining a healthy lifestyle is important during cancer treatment and beyond. Your health care team can help you make healthy changes and find helpful resources. 

Nutrition: During treatment, people may lose weight or have trouble tasting food. Eat what you can when you can during treatment. These symptoms are often temporary, and eating smaller portions every 2 to 3 hours may help. It’s important to avoid foods that may trigger acid reflux, such as acidic, greasy, or spicy foods. Some patients may need a feeding tube during treatment. If you had surgery to treat esophageal cancer, your stomach may not be able to hold food and digest like it used to. You may need to eat small amounts of food more often.

Swallowing Tips: Esophageal cancer can make swallowing hard, which can affect nutrition. Treatment can help by shrinking the cancer. Sometimes after treatment, the esophagus becomes narrow. Doctors can use a dilation procedure or place a stent to help open it up. 

Clinical Trials

Clinical trials help determine new treatment options for diseases and conditions. Patients with esophageal cancer have access to clinical trials. Speak to your doctor to determine if there is a trial that would work best for you.

When to See a Specialist

If you or a loved one have symptoms or a family history of esophageal cancer, it’s important to be evaluated by a gastroenterologist.

At National Jewish Health in Denver, Colorado, our gastroenterologists treat hundreds of patients with gastrointestinal cancers each year. Learn more about our gastroenterology program or use the button below to make an appointment.