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Esophageal Cancer

(Cancer of the Esophagus)

By

Anthony Villano

, MD, Fox Chase Cancer Center

Reviewed/Revised Oct 2023
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Worldwide in 2018, esophageal cancer was the 7th most commonly diagnosed type of cancer and the 6th leading cause of cancer deaths with about 572,000 new cases and 508,000 deaths.

In the United States, esophageal cancer is not as common. In the United States in 2023, cancer of the esophagus will account for an estimated 21,560 new cases and 16,120 deaths.

The most common types of esophageal cancer develop in the cells that line the wall of the esophagus and include

  • Squamous cell carcinoma, which is more common in the upper part of the esophagus

  • Adenocarcinoma, which is more common in the lower part

These cancers may appear as a narrowing (stricture) of the esophagus, a lump, an abnormal flat area (plaque), or an abnormal connection (fistula) between the esophagus and the airways that supply the lungs.

Squamous cell carcinoma is the most common esophageal cancer worldwide, but, in the United States, adenocarcinoma is more common. In the United States, squamous cell carcinoma is more common among men than women and more common among Black than White people.

Less common types of esophageal cancer include leiomyosarcomas (cancers of the smooth muscle of the esophagus) and metastatic cancer (cancer that has spread from elsewhere in the body).

Risk Factors for Esophageal Cancer

The main risk factors for esophageal cancer are

Most adenocarcinomas develop in people who have a precancerous condition called Barrett esophagus. Barrett esophagus develops from prolonged irritation of the esophagus caused by the repeated backflow of stomach acid (gastroesophageal reflux Gastroesophageal Reflux Disease (GERD) In gastroesophageal reflux disease, stomach contents, including acid and bile, flow backward from the stomach into the esophagus, causing inflammation in the esophagus and pain in the bottom... read more Gastroesophageal Reflux Disease (GERD) ). People who have obesity have an increased risk of adenocarcinoma because of their higher risk of gastroesophageal reflux.

Symptoms of Esophageal Cancer

Early-stage esophageal cancer may not cause any symptoms.

As the growing cancer narrows the esophagus, the first symptom of esophageal cancer is usually difficulty in swallowing Difficulty Swallowing Some people have difficulty swallowing (dysphagia). In dysphagia, foods and/or liquids do not move normally from the throat (pharynx) to the stomach. People feel as though food or liquids become... read more solid foods. Several weeks later, swallowing soft foods and then liquids and saliva becomes difficult.

Weight loss is common, even when the person continues to eat well. People may have chest pain, which feels like it travels to their back.

As the cancer progresses, it commonly invades various nerves and other tissues and organs. The tumor may compress the nerve that controls the vocal cords, which can lead to hoarseness. Compression of surrounding nerves may cause spinal pain, paralysis of the diaphragm, and hiccups.

The cancer usually spreads to the lungs, where it may cause shortness of breath, and to the liver, where it may cause fever and abdominal swelling. Spread to bones may cause pain. Spread to the brain may cause headache, confusion, and seizures. Spread to the intestines may cause vomiting, blood in the stool, and iron deficiency anemia Iron Deficiency Anemia Iron deficiency anemia results from low or depleted stores of iron, which is needed to produce red blood cells. Excessive bleeding is the most common cause. People may be weak, short of breath... read more . Spread to the kidneys often causes no symptoms.

In late stages, the cancer may completely block the esophagus. Swallowing becomes impossible, so secretions build up in the mouth, which can be very distressing.

Diagnosis of Esophageal Cancer

  • Endoscopy and biopsy

  • Barium swallow

  • Computed tomography (CT)

  • PET-CT and ultrasonography

Endoscopy Endoscopy Endoscopy is an examination of internal structures using a flexible viewing tube (endoscope). In addition to examinations, doctors can use endoscopy to do biopsies and give treatment. Endoscopes... read more , in which a flexible viewing tube (endoscope) is passed through the mouth to view the esophagus, is the best diagnostic procedure if esophageal cancer is suspected. Endoscopy also allows the doctor to remove a tissue sample (biopsy) and loose cells (brush cytology) for examination under a microscope.

An x-ray procedure called a barium swallow (in which the person swallows a solution of barium, which shows up on x-rays) can also show the obstruction.

Basic blood tests are done.

Treatment of Esophageal Cancer

  • Surgical removal

  • Chemotherapy combined with radiation (chemoradiation)

  • Immunotherapy combined with chemotherapy for advanced cancer

  • Relief of symptoms

Doctors sometimes treat shallow (superficial) adenocarcinomas by doing endoscopic resection, which means the adenocarcinomas are removed during the endoscopy. Endoscopic resection is less invasive and thus less risky than doing a surgical operation to remove the cancer. People whose cancer is removed early may not require chemotherapy or radiation. However, most esophageal cancers are treated with chemoradiation (see Combination Cancer Therapy Combination Cancer Therapy Cancer drugs are most effective when given in combination. The rationale for combination therapy is to use drugs that work by different mechanisms, thereby decreasing the likelihood that resistant... read more ) before surgery is done. Sometimes chemoradiation done before surgery can increase survival.

Immunotherapy Immunotherapy for Cancer Immunotherapy is used to stimulate the body's immune system against cancer. These treatments target specific genetic characteristics of the tumor cells. The genetic characteristics of tumors... read more involves giving medications that stimulate the body's immune system to fight the cancer. These treatments target specific genetic characteristics of the tumor cells. Immunotherapy is sometimes given after tumor resection. Immunotherapy combined with chemotherapy is the recommended treatment for advanced squamous cell carcinoma of the esophagus and may be recommended for treatment of adenocarcinoma of the esophagus.

Other measures are aimed at relieving symptoms, particularly difficulty swallowing. Such measures include stretching open the narrowed area of the esophagus and then inserting a flexible metal mesh tube (a stent) to keep the esophagus open, burning the cancer with a laser to widen the opening, and using radiation therapy to destroy the cancer tissue obstructing the esophagus.

Shallow (superficial) adenocarcinomas sometimes are cured by being burned away with radio waves (radiofrequency ablation).

Another technique for symptom relief is photodynamic therapy, in which a light-sensitive dye (contrast agent) is given by vein (intravenously) 48 hours before treatment. The dye is absorbed by cancer cells to a much greater degree than by the cells of normal surrounding esophageal tissue. When activated by light from a laser passed into the esophagus through an endoscope, the dye destroys cancer tissue, thus opening the esophagus. Photodynamic therapy destroys obstructing lesions more rapidly than radiation or chemotherapy in people who cannot tolerate surgery because of poor health.

Adequate nutrition makes any type of treatment more feasible and tolerable. People who can swallow may receive concentrated liquid nutritional supplements. People who cannot swallow may need to be fed through a tube placed through the wall of the abdomen into their stomach (gastrostomy tube Inserting a feeding tube directly into the stomach or intestine Tube feeding may be used to feed people whose digestive tract is functioning normally but who cannot eat enough to meet their nutritional needs. Such people include those with the following... read more Inserting a feeding tube directly into the stomach or intestine ).

Prognosis for Esophageal Cancer

Because esophageal cancer usually is not diagnosed until the disease has spread, the death rate is high. Fewer than 5% of people survive more than 5 years. Many die within a year of noticing the first symptoms. Exceptions include adenocarcinomas that are diagnosed when they are still very shallow (superficial).

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