Esophageal cancers develop in the cells that line the wall of the esophagus Throat and Esophagus The throat (pharynx— see also Throat) lies behind and below the mouth. When food and fluids leave the mouth, they pass through the throat. Swallowing of food and fluids begins voluntarily and... read more (the tube that connects the throat to the stomach).
Tobacco and alcohol use, human papillomavirus infections, and certain esophageal disorders are major risk factors for certain types of esophageal cancer.
Typical symptoms include difficulty swallowing, weight loss, and, later, pain.
The diagnosis is based on an endoscopy.
Unless discovered early, almost all cases of esophageal cancer are fatal.
Surgery, chemotherapy, and various other therapies can help relieve the symptoms.
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.
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).
Each year in the United States, cancer of the esophagus accounts for an estimated 18,440 cases and 16,170 deaths. Both squamous cell carcinoma and adenocarcinoma are more common among men than women. Squamous cell carcinoma is more common among blacks, whereas adenocarcinoma is more common among whites. Squamous cell carcinoma is the most common esophageal cancer worldwide, but the frequency of adenocarcinoma has been increasing rapidly in the United States and it is now the most common type, especially among white men.
Risk Factors of Esophageal Cancer
Tobacco use (any kind) and alcohol are the main risk factors for developing esophageal cancer, although more so for squamous cell carcinoma than for adenocarcinoma. People who have had certain human papillomavirus infections Human Papillomavirus (HPV) Infection Human papillomavirus (HPV) causes warts. Some types of HPV cause skin warts, and other types cause genital warts (growths in or around the vagina, penis, or rectum). Infection with some HPV... read more , who have had head and neck cancer Overview of Mouth, Nose, and Throat Cancers Cancers of the mouth, nose, and throat develop in almost 65,000 people in the United States each year. These cancers are more common among men because male smokers continue to outnumber female... read more , or who have undergone radiation therapy to the esophagus for treatment of other nearby cancers are at greater risk of developing esophageal cancer.
People with an existing disorder of the esophagus, such as achalasia Achalasia Achalasia is a disorder in which the rhythmic contractions of the esophagus (called peristalsis) are missing or impaired, the lower esophageal sphincter does not relax normally, and the resting... read more , esophageal webs Esophageal Webs Esophageal webs are thin membranes that grow across the inside of the upper part of the esophagus and may cause difficulty swallowing (dysphagia). (See also Overview of Esophageal Obstructions... read more (Plummer-Vinson syndrome), or narrowing due to having once swallowed a corrosive substance (such as lye), are also at greater risk of developing squamous cell esophageal cancer. 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 ). Obese people have an increased risk of adenocarcinoma because of their higher risk of gastroesophageal reflux.
Symptoms of Esophageal Cancer
Early-stage esophageal cancer may go unnoticed. 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, which develops as the growing cancer narrows the esophagus. 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
Computed tomography (CT)
Endoscopy Endoscopy Endoscopy is an examination of internal structures using a flexible viewing tube (endoscope). Endoscopy can also be used to treat many disorders because doctors are able to pass instruments... 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. Computed tomography Computed Tomography and Magnetic Resonance Imaging of the Digestive Tract Computed tomography (CT— see also Computed Tomography (CT)) and magnetic resonance imaging (MRI— see also Magnetic Resonance Imaging (MRI)) scans are good tools for assessing the size and location... read more of the chest and abdomen and ultrasonography done through an endoscope (see ultrasound scanning Ultrasound Scanning (Ultrasonography) of the Abdomen Ultrasound scanning uses sound waves to produce pictures of internal organs ( see also Ultrasonography). An ultrasound scan can show the size and shape of many organs, such as the liver and... read more ) inserted in the esophagus may be used to further assess the extent of the cancer.
Prognosis of 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). These shallow cancers sometimes are cured by being burned away with radio waves (radiofrequency ablation) or cut away through an endoscope.
Because nearly all cases of esophageal cancer are fatal, the doctor’s main objective is to control symptoms, especially pain Pain Many fatal illnesses cause similar symptoms, including pain, shortness of breath, digestive problems, incontinence, skin breakdown, and fatigue. Depression and anxiety, confusion and unconsciousness... read more and difficulty swallowing Difficulty swallowing Many fatal illnesses cause similar symptoms, including pain, shortness of breath, digestive problems, incontinence, skin breakdown, and fatigue. Depression and anxiety, confusion and unconsciousness... read more , which can be very frightening to the person and loved ones.
Treatment of Esophageal Cancer
Chemotherapy combined with radiation therapy
Immunotherapy combined with chemotherapy for advanced cancer
Relief of symptoms
Surgery to remove a tumor offers the most prolonged relief but seldom cures, because the cancer usually has spread by the time of surgery. Chemotherapy combined with radiation therapy ( 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 ) may relieve symptoms and lengthen survival time by a few months. Sometimes radiation therapy combined with chemotherapy is done before surgery and 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 drugs that stimulate the body's immune system to fight the cancer. These treatments target specific genetic characteristics of the tumor cells. Immunotherapy combined with chemotherapy is a recommended treatment for advanced squamous cell carcinoma of the esophagus and 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.
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 ).
Because death is likely, a person with esophageal cancer should make all necessary plans. The person should have frank discussions with the doctor about wishes for medical care (see Advance Directives Advance Directives Health care advance directives are legal documents that communicate a person’s wishes about health care decisions in the event the person becomes incapable of making health care decisions. There... read more ) and the need for end-of-life care Treatment Options at the End of Life Often, the available choices for end-of-life care involve a decision whether to accept the likelihood of dying sooner but to be more comfortable or attempt to live slightly longer by receiving... read more .