Understanding Esophageal Cancer

Esophageal cancer is a rare condition of the digestive system. It’s important to know:

  • Esophageal cancer is up to four times more common in men.
  • Chronic gastroesophageal reflux disease, or GERD, is a risk factor for the most common type of esophageal cancer in the U.S.
  • Heavy smoking and drinking are risk factors for the second most common type.
  • This cancer is uncommon overall, but the most common type has risen dramatically in recent decades. 
  • Specialized care makes it possible to catch the disease’s early signs, giving you a better chance for successful treatment.

What is esophageal cancer?

Your esophagus is the muscular tube that connects your throat (larynx) to your stomach. When you swallow food, layers of muscle move it down the esophagus to the stomach.

Esophageal cancer happens when abnormal cells form in the tissue that lines the esophagus. As the cells multiply, cancer invades layers of the esophagus and may spread to other parts of the body. 
 

Anatomy of the Upper Digestive System

Medical illustration of the upper digestive system, including esophagus, stomach, liver, small intestine, and large intestine

Who gets esophageal cancer?

An estimated 17,650 people in the U.S. are expected to be diagnosed with esophageal cancer in 2019. Esophageal cancer accounts for 1% of new cancer diagnoses each year. At the same time, rates for the most common type, esophageal adenocarcinoma, have multiplied since the 1970s. Doctors suspect the rise is linked to increases in obesity and GERD.

GERD

In GERD, also known as acid reflux, stomach acid travels up into the lower part of the esophagus. GERD is one of the biggest risk factors for esophageal adenocarcinoma. Still, most people with GERD will not go on to develop cancer.  

GERD risk factors: You are more likely to have reflux if you are overweight or have a hiatal hernia. In this condition, part of the stomach bulges up through an opening (the hiatus) in the diaphragm (the muscle between the abdomen and chest). The hernia can weaken muscles in the lower esophagus. 

Barrett’s esophagus: Frequent reflux can damage the lining of the esophagus. In some people, cells in this area die and are replaced with cells more like the ones in your stomach. This condition, called Barrett’s esophagus, increases your risk of esophageal cancer.
 

Other risk factors for esophageal cancer

  • Age: Esophageal cancer is more common in people ages 45 to 70.
  • Gender: It’s three to four times more common in men.
  • Alcohol use: Regularly drinking alcohol, including beer and wine, increases risk.
  • Tobacco use: Smoking and any other use of tobacco irritates the lining of the esophagus and may increase risk. 
  • Diet: Not getting enough fruits, vegetables and certain vitamins can make esophageal cancer more likely.
  • Race: White people are more likely to get the most common type of esophageal cancer. The less common type affects other racial and ethnic groups more often. 
  • Health history: Conditions affecting the esophagus, such as achalasia, increase your risk. In people with achalasia, the muscles at the bottom of the lower esophagus make it difficult for food to pass. People with a history of cancers linked to smoking, such as lung cancer, also may have a higher risk of esophageal cancer.

Esophageal cancer outcomes

Survival rates for esophageal cancer are discouraging because it’s often found in later stages, when it’s tougher to treat. At the same time, survival rates are averages and can’t predict the outcome for any one person. They are also based, by definition, on the treatments that were available five or more years ago.

Signs of hope: Nearly 47% of patients live at least five years after diagnosis if cancer is found before it spreads, according to the National Cancer Institute. At the OHSU Knight Cancer Institute, world-class researchers are dedicated to finding new ways to detect cancer early.

Quality of life: Your care team at the Knight Cancer Institute will strive to give you the longest life and highest quality of life possible. Though esophageal cancer sometimes cannot be cured, treatment can keep you comfortable and help you reach new goals.

Esophageal cancer symptoms

You may not notice symptoms in early stages. In later stages, tumor growth may make it difficult for the esophagus to do its job. Some symptoms may be similar to those of other esophageal conditions, including reflux and achalasia. 

Symptoms include:

  • Difficulty swallowing
  • Choking while eating
  • Heartburn or indigestion
  • Hoarse voice that does not go away
  • Pain in your throat or upper chest
  • Vomiting 
  • Coughing up blood 
  • Black, tarlike stools

If you have these symptoms, especially if they don’t get better, it’s important to talk with your doctor.

Screening for esophageal cancer

If you face a higher risk for esophageal cancer, such as having Barrett’s esophagus, regular testing helps detect even the slightest change. Our team may do screening tests such as: 

  • Upper endoscopy: We look at the lining of your esophagus by easing an endoscope — a thin, flexible tube with a camera at the tip — down the throat. 
  • Double balloon enteroscopy: When needed, we offer this advanced technique. We use balloons to anchor the endoscope so we can see harder-to-reach areas.

Types of esophageal cancer

Cell type

Adenocarcinoma: This is the most common type in the U.S. It starts in the mucus-producing cells that line the surface of the esophagus. Adenocarcinoma often develops in the lower esophagus near the stomach. It may also occur where the esophagus meets the stomach, an area called the gastroesophageal junction. Adenocarcinomas that form there are not technically esophageal cancer but are treated similarly.

Squamous cell carcinoma: This type starts at the surface of the esophagus and often higher in the esophagus, near the chest and neck. Most esophageal squamous cell carcinomas in the U.S. are linked to a history of smoking and drinking.

Whether surgery is an option

Whether your tumor can be removed with surgery plays a key role in treatment recommendations. Your tumor will be described as:

  • Resectable: This means a tumor can be removed with surgery. 
  • Unresectable: This means the cancer cannot be removed with surgery. Cancers that have spread to organs or distant parts of the body are unresectable. They are best treated with radiation, chemotherapy or other approaches. 

Grading esophageal cancer

Grading helps your care team judge how aggressive your cancer might be. This helps guide treatment recommendations. 

A doctor called a pathologist looks at a tumor sample under a microscope and compares it with normal tissue. The doctor grades esophageal cancer on a scale of 1 to 3 (or finds that the grade can’t be determined): 

  • G1: The cancer is low grade and looks more like normal tissue.
  • G2: The cancer looks less like normal tissue. 
  • G3: The cancer is high grade and looks abnormal. 

Higher-grade tumors are more likely to grow and spread. Your team may recommend more aggressive treatment than for a low-grade tumor of the same stage.

Staging esophageal cancer

Staging describes a tumor’s size and location. It helps your doctors understand how advanced the cancer is so they can recommend the most effective treatments. 

Staging takes into account factors such as:

  • Your cancer’s grade and how it looks under a microscope
  • A physical exam
  • Imaging tests
  • Whether the cancer has grown through the wall of the esophagus
  • Whether it has spread to lymph nodes (bean-size structures that play a role in the immune system) or other body parts

This is a simple description of staging for adenocarcinoma of the esophagus, the most common type. Find a more detailed outline at the American Cancer Society website. 

Stage IIA Adenocarcinoma of the Esophagus (esophageal cancer), with inset showing detail of the layers of the esophagus
In this stage of the most common esophageal cancer in the U.S., the tumor has grown into layers of the esophagus.

Stage I: The cancer has grown into layers below the surface of the esophagus but hasn’t spread to any lymph nodes or distant organs. The cancer is more likely to be Grade 1 or 2.

Stage II: The cancer invades more deeply into layers of the esophagus and may have spread to one or two nearby lymph nodes. It can be any grade.

Stage III: The cancer has spread as far as the outer layer of the esophagus and to as many as six nearby lymph nodes. Or it has spread to the diaphragm or to tissue covering the lungs or heart, and to as many as two lymph nodes. 

Stage IV: The cancer affects as many as six nearby lymph nodes; and the diaphragm, lung or heart coverings; or vital structures such as the windpipe or spine. Or it has spread to layers of the esophagus and to seven or more lymph nodes. Or it has spread to distant lymph nodes or organs.

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