Esophageal cancer

Overview

Esophageal cancer is cancer that occurs in the esophagus — a long, hollow tube that runs from your throat to your stomach. Your esophagus helps move the food you swallow from the back of your throat to your stomach to be digested.

Esophageal cancer usually begins in the cells that line the inside of the esophagus. Esophageal cancer can occur anywhere along the esophagus. More men than women get esophageal cancer.

Esophageal cancer is the sixth most common cause of cancer deaths worldwide. Incidence rates vary within different geographic locations. In some regions, higher rates of esophageal cancer may be attributed to tobacco and alcohol use or particular nutritional habits and obesity.

Symptoms

Signs and symptoms of esophageal cancer include:

• Difficulty swallowing (dysphagia)
• Weight loss without trying
• Chest pain, pressure or burning
• Worsening indigestion or heartburn
• Coughing or hoarseness

Early esophageal cancer typically causes no signs or symptoms.

When to see a doctor

Make an appointment with your doctor if you have any persistent signs and symptoms that worry you.

If you've been diagnosed with Barrett's esophagus, a precancerous condition caused by chronic acid reflux, your risk of esophageal cancer is higher. Ask your doctor what signs and symptoms to watch for that may signal that your condition is worsening.

Screening for esophageal cancer may be an option for people with Barrett's esophagus. If you have Barrett's esophagus, discuss the pros and cons of screening with your doctor.

Causes

It's not exactly clear what causes esophageal cancer.

Esophageal cancer occurs when cells in the esophagus develop changes (mutations) in their DNA. The changes make cells grow and divide out of control. The accumulating abnormal cells form a tumor in the esophagus that can grow to invade nearby structures and spread to other parts of the body.

Types of esophageal cancer

Esophageal cancer is classified according to the type of cells that are involved. The type of esophageal cancer you have helps determine your treatment options. Types of esophageal cancer include:

• Adenocarcinoma. Adenocarcinoma begins in the cells of mucus-secreting glands in the esophagus. Adenocarcinoma occurs most often in the lower portion of the esophagus. Adenocarcinoma is the most common form of esophageal cancer in the United States, and it affects primarily white men.
• Squamous cell carcinoma. The squamous cells are flat, thin cells that line the surface of the esophagus. Squamous cell carcinoma occurs most often in the upper and middle portions of the esophagus. Squamous cell carcinoma is the most prevalent esophageal cancer worldwide.
• Other rare types. Some rare forms of esophageal cancer include small cell carcinoma, sarcoma, lymphoma, melanoma and choriocarcinoma.

Risk factors

It's thought that chronic irritation of your esophagus may contribute to the changes that cause esophageal cancer. Factors that cause irritation in the cells of your esophagus and increase your risk of esophageal cancer include:

• Having gastroesophageal reflux disease (GERD)
• Smoking
• Having precancerous changes in the cells of the esophagus (Barrett's esophagus)
• Being obese
• Drinking alcohol
• Having bile reflux
• Having difficulty swallowing because of an esophageal sphincter that won't relax (achalasia)
• Having a steady habit of drinking very hot liquids
• Not eating enough fruits and vegetables
• Undergoing radiation treatment to the chest or upper abdomen

Complications

As esophageal cancer advances, it can cause complications, such as:

• Obstruction of the esophagus. Cancer may make it difficult for food and liquid to pass through your esophagus.
• Pain. Advanced esophageal cancer can cause pain.
• Bleeding in the esophagus. Esophageal cancer can cause bleeding. Though bleeding is usually gradual, it can be sudden and severe at times.

Prevention

You can take steps to reduce your risk of esophageal cancer. For instance:

• Quit smoking. If you smoke, talk to your doctor about strategies for quitting. Medications and counseling are available to help you quit. If you don't use tobacco, don't start.
• Drink alcohol in moderation, if at all. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women and up to two drinks a day for men.
• Eat more fruits and vegetables. Add a variety of colorful fruits and vegetables to your diet.
• Maintain a healthy weight. If you are overweight or obese, talk to your doctor about strategies to help you lose weight. Aim for a slow and steady weight loss of 1 or 2 pounds a week.

Diagnosis

Tests and procedures used to diagnose esophageal cancer include:

• Barium swallow study. During this study, you swallow a liquid that includes barium and then undergo X-rays. The barium coats the inside of your esophagus, which then shows any changes to the tissue on the X-ray.
• Using a scope to examine your esophagus (endoscopy). During endoscopy, your doctor passes a flexible tube equipped with a video lens (videoendoscope) down your throat and into your esophagus. Using the endoscope, your doctor examines your esophagus, looking for cancer or areas of irritation.
• Collecting a sample of tissue for testing (biopsy). Your doctor may use a special scope passed down your throat into your esophagus (endoscope) to collect a sample of suspicious tissue (biopsy). The tissue sample is sent to a laboratory to look for cancer cells.

Determining the extent of the cancer

Once a diagnosis of esophageal cancer is confirmed, your doctor may recommend additional tests to determine whether your cancer has spread to your lymph nodes or to other areas of your body.

Tests may include:

• Bronchoscopy
• Endoscopic ultrasound (EUS)
• Computerized tomography (CT)
• Positron emission tomography (PET)

Your doctor uses the information from these procedures to assign a stage to your cancer. The stages of esophageal cancer are indicated by Roman numerals that range from 0 to IV, with the lowest stages indicating that the cancer is small and affects only the superficial layers of your esophagus. By stage IV, the cancer is considered advanced and has spread to other areas of the body.

The cancer staging system continues to evolve and is becoming more complex as doctors improve cancer diagnosis and treatment. Your doctor uses your cancer stage to select the treatments that are right for you.

Treatment

What treatments you receive for esophageal cancer are based on the type of cells involved in your cancer, your cancer's stage, your overall health and your preferences for treatment.

Surgery

Surgery to remove the cancer can be used alone or in combination with other treatments.

Operations used to treat esophageal cancer include:

• Surgery to remove very small tumors. If your cancer is very small, confined to the superficial layers of your esophagus and hasn't spread, your surgeon may recommend removing the cancer and margin of healthy tissue that surrounds it. Surgery can be done using an endoscope passed down your throat and into your esophagus.
• Surgery to remove a portion of the esophagus (esophagectomy). During esophagectomy, the surgeon removes the portion of your esophagus that contains the cancer, along with a portion of the upper part of your stomach, and nearby lymph nodes. The remaining esophagus is reconnected to your stomach. Usually this is done by pulling the stomach up to meet the remaining esophagus.
• Surgery to remove part of your esophagus and the upper portion of your stomach (esophagogastrectomy). During esophagogastrectomy, the surgeon removes part of your esophagus, nearby lymph nodes and a larger part of your stomach. The remainder of your stomach is then pulled up and reattached to your esophagus. If necessary, part of your colon is used to help join the two.

Esophageal cancer surgery carries a risk of serious complications, such as infection, bleeding and leakage from the area where the remaining esophagus is reattached to the stomach.

Surgery to remove your esophagus can be performed as an open procedure using large incisions or with special surgical tools inserted through several small incisions in your skin (laparoscopically). How your surgery is performed depends on your individual situation and your surgeon's particular approach to managing it.

Treatments for complications

Treatments for esophageal obstruction and difficulty swallowing (dysphagia) can include:

• Relieving esophageal obstruction. If your esophageal cancer has narrowed your esophagus, a surgeon may use an endoscope and special tools to place a metal tube (stent) to hold the esophagus open. Other options include surgery, radiation therapy, chemotherapy, laser therapy and photodynamic therapy.
• Providing nutrition. Your doctor may recommend a feeding tube if you're having trouble swallowing or if you're having esophagus surgery. A feeding tube allows nutrition to be delivered directly to your stomach or small intestine, giving your esophagus time to heal after cancer treatment.

Chemotherapy

Chemotherapy is drug treatment that uses chemicals to kill cancer cells. Chemotherapy drugs are typically used before (neoadjuvant) or after (adjuvant) surgery in people with esophageal cancer. Chemotherapy can also be combined with radiation therapy.

In people with advanced cancer that has spread beyond the esophagus, chemotherapy may be used alone to help relieve signs and symptoms caused by the cancer.

The chemotherapy side effects that you experience depend on which chemotherapy drugs you receive.

Radiation therapy

Radiation therapy uses high-energy beams, such as X-rays and protons, to kill cancer cells. Radiation typically will come from a machine outside your body that aims the beams at your cancer (external beam radiation). Or, less commonly, radiation can be placed inside your body near the cancer (brachytherapy).

Radiation therapy is most often combined with chemotherapy in people with esophageal cancer. It's typically used before surgery, or occasionally after surgery. Radiation therapy is also used to relieve complications of advanced esophageal cancer, such as when a tumor grows large enough to stop food from passing to your stomach.

Side effects of radiation to the esophagus include sunburn-like skin reactions, painful or difficult swallowing, and damage to nearby organs, such as the lungs and heart.

Combined chemotherapy and radiation

Combining chemotherapy and radiation therapy may enhance the effectiveness of each treatment. Combined chemotherapy and radiation may be the only treatment you receive, or combined therapy can be used before surgery. But combining chemotherapy and radiation treatments increases the likelihood and severity of side effects.

Targeted drug therapy

Targeted drug treatments focus on specific weaknesses present within cancer cells. By blocking these weaknesses, targeted drug treatments can cause cancer cells to die. For esophageal cancer, targeted drugs are usually combined with chemotherapy for advanced cancers or cancers that don't respond to other treatments.

Immunotherapy

Immunotherapy is a drug treatment that helps your immune system to fight cancer. Your body's disease-fighting immune system might not attack cancer because the cancer cells produce proteins that make it hard for the immune system cells to recognize the cancer cells as dangerous. Immunotherapy works by interfering with that process. For esophageal cancer, immunotherapy might be used when the cancer is advanced, cancer has come back or the cancer has spread to other parts of the body.

Alternative medicine

Complementary and alternative therapies may help you cope with the side effects of cancer and cancer treatment. For instance, people with esophageal cancer may experience pain caused by cancer treatment or by a growing tumor. Your doctor can work to control your pain by treating the cause or with medications. Still, pain may persist, and complementary and alternative therapies may help you cope.

Options include:

• Acupuncture
• Guided imagery
• Massage
• Relaxation techniques

Ask your doctor whether these options are safe for you.

Coping and support

Coping with the shock, fear and sadness that come with a cancer diagnosis can take time. You may feel overwhelmed just when you need to make crucial decisions. With time, each person finds a way of coping and coming to terms with the diagnosis.

Until you find what brings you the most comfort, consider trying to:

• Find out enough about esophageal cancer to make decisions about your care. Ask your doctor for the specifics about your cancer, such as its type and stage. And ask for recommended sources of information where you can learn more about your treatment options. The National Cancer Institute and the American Cancer Society are good places to start.
• Stay connected to friends and family. Your friends and family can provide a crucial support network for you during your cancer treatment. As you begin telling people about your esophageal cancer diagnosis, you'll likely get offers for help. Think ahead about things you may like help with, whether it's having someone to talk to if you're feeling low or getting help preparing meals.

• Find someone to talk to. You might have a close friend or family member who's a good listener. Or talk to a counselor, medical social worker, or pastoral or religious counselor.

  Consider joining a support group for people with cancer. You may find strength and encouragement in being with people who are facing the same challenges you are. Ask your doctor, nurse or social worker about groups in your area. Or try online message boards, such as those available through the American Cancer Society.

Preparing for an appointment

If your family doctor suspects you have esophageal cancer, you may be referred to a number of doctors who will help evaluate your condition. Your health care team may include doctors who:

• Evaluate the esophagus (gastroenterologists)
• Treat cancer with chemotherapy and other medications (oncologists)
• Perform surgery (surgeons)
• Use radiation to treat cancer (radiation oncologists)

To get the most from your appointment, it's a good idea to be well prepared. Here's some information to help you get ready, and to know what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.
• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins or supplements you're taking.
• Consider taking a family member or friend along. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Preparing a list of questions will help you make the most of your time with your doctor. For esophageal cancer, some basic questions to ask your doctor include:

• Where is my esophageal cancer?
• How advanced is my cancer?
• Can you explain the pathology report to me?
• What other tests do I need?
• What are my treatment options?
• What are the potential side effects of each treatment option?
• Is there one treatment option you feel is the best?
• What would you recommend to a friend or family member in my situation?
• Should I see a specialist?
• Are there any brochures or other printed material that I can take with me? What websites do you recommend?
• What will determine whether I should plan for a follow-up visit?

Don't hesitate to ask any other questions that occur to you during your appointment.

A full range of treatment options to consider

Mayo Clinic doctors will work with you to review all of your treatment options and choose the treatment that best suits your needs and goals.

The range of treatments offered to people with esophageal cancer includes chemotherapy, radiation therapy, proton beam therapy, and minimally invasive and traditional operations, such as esophagectomy.