Cancer in the tube connecting throat to stomach often is diagnosed at a later stage. It is important to seek evaluation for symptoms such as difficult or painful swallowing.
What is esophageal cancer?
Esophageal cancer develops in the esophagus, the long, hollow tube that connects your mouth to your stomach and helps transport food and liquids into your stomach. Esophageal cancer occurs when cells in the esophagus acquire mutations that cause them to grow uncontrollably.
The American Cancer Society estimates that esophageal cancer makes up about 1% of all cancer diagnoses in the U.S. Esophageal cancer can affect individuals of all sexes, genders, and racial or ethnic backgrounds.
AHN approaches esophageal cancer with a multidisciplinary team of specialists working together to create individualized treatment plans. This coordinated team typically includes:
- Surgical oncologists and gastroenterologists: Diagnose and stage the cancer, perform endoscopies. Perform surgery to remove the tumor.
- Medical oncologists: Administer chemotherapy and targeted therapies. Learn more about medical oncology.
- Radiation oncologists: Deliver radiation therapy. Learn more about radiation oncology.
- Radiologists: Interpret imaging scans (CT, PET, MRI) to assess the extent of the cancer.
- Pathologists: Examine tissue samples to confirm the diagnosis and determine the cancer's characteristics.
- Registered dietitians: Help manage nutritional needs during and after treatment.
- Supportive care specialists: Highly trained professionals who provide assistance with pain management, emotional support, and other needs. Learn more about esophageal support services.
AHN Esophageal and Gastric Center of Excellence
At the Esophageal and Gastric Center of Excellence, our specialists work collaboratively to develop an individualized plan of care that focuses on your needs.
At the AHN Cancer Institute, we have a personalized approach to esophageal cancer care. We consider your preferences, needs, and overall health when tailoring a care plan for you. All our specialists work together to review your case to determine the most effective treatment plan available. Our whole-person approach to care includes robust support services that includes nutritional support, patient support groups, and palliative care. AHN also offers an innovative cancer genetics program to identify potential inherited risk factors and develop individualized treatment plans.
We work with AHN’s nationally recognized Esophageal Institute to obtain the best results possible. Features of our program include:
- Advanced technology: We perform surgery using the smallest incisions possible, leading to an easier and quicker recovery.
- Collaborative care: We bring the most complex esophageal cancer cases to our tumor board, which includes gastroenterologists, surgeons, oncologists, radiologists, pathologists, and researchers. You benefit from the experience and knowledge of these experts.
- Convenient services: We designed our facility around the needs of our patients. For your convenience, you can take care of tests, appointments, treatment, and rehab (if needed) at many of our facilities. Plus, if you're having pain or other side effects, you get prompt treatment from one of our specialists at our After-Hours Oncology Clinic, instead of waiting in an emergency room.
- Quality esophageal cancer care close to home: You don’t have to travel far to get the comprehensive care you need. You can focus your energy on your health, not on traveling.
- Research-driven treatment: Our robust clinical trials program offers options for novel treatments. If you meet the eligibility requirements, you could take part in important medical research that helps discover a revolutionary treatment.
Esophageal cancer symptoms and signs
The symptoms of esophageal cancer can be subtle at first, and sometimes people don't notice them until the cancer has grown. Here are some of the most common ones:
- Difficulty swallowing (Dysphagia): This is the most frequent symptom. You might feel like food is getting stuck in your throat or chest. It often starts with difficulty swallowing solid foods like meat or bread and then progresses to difficulty swallowing even soft foods or liquids. At times, you can experience pain with swallowing.
- Weight loss: Unexplained weight loss, even when you haven't changed your diet or exercise habits, can be a sign. This is often because it becomes difficult or painful to eat enough food.
- Chest pain or pressure: You might experience pain, pressure, or a burning sensation in your chest. This can sometimes be mistaken for acid reflux.
- Heartburn or indigestion: Esophageal cancer can worsen existing heartburn or indigestion, or cause it to start even if you've never had it before.
- Hoarseness or chronic cough: The cancer can affect the nerves that control your voice box, leading to hoarseness. It can also irritate the esophagus and cause a persistent cough.
- Nausea and vomiting: Some people may experience nausea or vomiting, especially if the esophagus is partially blocked by the tumor.
- Pain behind the breastbone or in the throat: This can be a more general pain that isn't necessarily related to swallowing.
- Black, tarry stools: This can indicate bleeding in the esophagus, which can be a sign of the cancer.
Causes and risk factors
There are two main types of esophageal cancer, and each one has different causes and risk factors. Squamous cell carcinoma develops when cells in the esophagus lining start to change due to long-term exposure to abrasive substances, like alcohol and nicotine. Adenocarcinoma starts in gland cells and often occurs from acid reflux (heartburn). Risk factors that contribute to squamous cell carcinoma include:
- Smoking: A major risk factor. The longer you smoke and the more you smoke, the higher your risk.
- Excessive alcohol consumption: Especially when combined with smoking, alcohol greatly increases the risk.
- Poor nutrition: A diet low in fruits and vegetables may increase the risk.
- Hot liquids: Regularly drinking very hot beverages may damage the esophageal lining over time.
- Chewing betel quid or paan: Common in some parts of Asia, this habit is strongly linked to squamous cell carcinoma.
- Plummer-Vinson syndrome: A rare condition causing difficulty swallowing due to small growths in the esophagus.
- Esophageal injury: Damage to the esophagus from swallowing harsh (caustic) substances can increase risk.
Risk factors that contribute to adenocarcinoma include:
- Chronic heartburn: Gastroesophageal reflux disease (GERD) is long-term, frequent heartburn increases the risk because stomach acid irritates the esophagus.
- Barrett's esophagus: Barrett’s esophagus develops when chronic GERD causes the normal esophageal lining to be replaced with tissue similar to the intestinal lining. It's a major risk factor for adenocarcinoma.
- Obesity: Being overweight or obese increases the risk, possibly due to increased GERD.
- Smoking: Smoking can also increase the risk of adenocarcinoma.
- Gender: Adenocarcinoma is more common in men than women.
- Age: The risk increases with age, with most cases diagnosed after age 50.
Esophageal cancer screening and diagnosis
Screening may be recommended for individuals at high risk, including those with Barrett's esophagus and long-standing, frequent GERD symptoms. Your AHN esophageal specialist will determine which screening method will be right for your specific needs.
Screening methods may include:
- Endoscopy: The primary screening method visualizes the lining of the esophagus to look for abnormal areas. A thin, flexible tube with a camera (endoscope) is inserted down the esophagus.
- Biopsies: If suspicious areas are seen, biopsies (small tissue samples) are taken for examination under a microscope to check for cancer cells or precancerous changes (dysplasia).
- Sponge: This minimally invasive technique is new approach to collect cells that analyze the presence of Barrett’s esophagus. It uses a small, coated pill attached to a string that is then swallowed. The coating expands to resemble a sponge. The sponge collects cells and then the provider removes the pill, which is then sent to a pathologist for examination. This is currently used in clinical trials.
If screening or symptoms suggest esophageal cancer, further diagnostic tests are needed to confirm the diagnosis and determine the extent of the cancer (staging).
Tests may include:
- Endoscopy with biopsy: This is crucial for confirming the diagnosis. Using an endoscope, your provider will collect samples (biopsies) to determine if there is a presence of cancer. The biopsies are examined by a pathologist.
- Barium swallow (esophagogram): To identify abnormalities in the structure or function of the esophagus, such as narrowing or blockages, doctors use a barium swallow study. While it can suggest cancer, it doesn't provide a definitive diagnosis. You drink a liquid containing barium, which coats the esophagus and makes it visible on X-rays.
- Endoscopic ultrasound: An endoscope with an ultrasound probe is inserted into the esophagus to obtain detailed images of the esophageal wall and surrounding tissues, including lymph nodes. It helps determine how deeply the cancer has invaded and if it has spread to nearby lymph nodes.
- Fine needle aspiration biopsy (FNAB): an endoscopic ultrasound can also be used to guide a needle to take a sample of suspicious lymph nodes.
- Computed tomography (CT) Scan: A CT scan looks for the spread of cancer to other parts of the body, such as the lungs, liver, and distant lymph nodes.
- Positron Emission Tomography (PET) Scan: A radioactive substance is injected into the body. Cancer cells absorb more of the substance than normal cells, making them visible on the PET scan. This test, often combined with a CT scan (PET/CT) is used to detect if cancer has spread throughout the body.
- Bronchoscopy: If the cancer is located in the upper esophagus, a bronchoscopy may be performed to check if the cancer has spread to the trachea (windpipe) or bronchi (airways into the lungs).
- Laparoscopy/Thoracoscopic surgery: In some cases, minimally invasive surgery may be used to examine the abdominal or chest cavity for signs of cancer spread.
Types and stages of esophageal cancer
When you're facing a possible diagnosis of esophageal cancer, it's helpful to understand the basics of the disease. There are two different types of esophageal cancer: squamous esophageal cancer and esophageal adenocarcinoma.
Squamous esophageal cancer
Squamous cell carcinoma starts in the flat cells that line the innermost part of the esophagus. This type of cancer is often associated with things like smoking and alcohol use.
Esophageal adenocarcinoma
Adenocarcinoma starts in the gland cells. These cells make fluids (like mucus) to help with digestion. Adenocarcinoma often develops as a result of long-term acid reflux (heartburn). It is important to know that even mild reflux can lead to esophageal cancer.
While squamous cell carcinoma and adenocarcinoma account for the vast majority of esophageal cancers, other, more rare types include:
- Small cell carcinoma: This is a very aggressive type of cancer that is similar to small cell lung cancer.
- Sarcoma: A cancer that arises from connective tissues in the esophagus, such as muscle or fat.
- Melanoma: Melanoma can, rarely, occur in the esophagus.
- Lymphoma: A cancer that originates in the lymphatic system and can sometimes affect the esophagus.
Esophageal cancer staging
Staging is like creating a "map" of how far the cancer has spread. This map helps your doctors determine the best treatment plan. The staging system uses numbers (0 to 4). The higher the number, the more the cancer has spread.Here's a general idea of what the stages mean:
- Stage 0 (Carcinoma in Situ): The cancer is only in the very top layer of cells lining the esophagus. It hasn't spread deeper.
- Stage 1: The cancer has grown deeper into the layers of the esophageal wall, but hasn't spread to lymph nodes (small bean-shaped organs that help fight infection).
- Stage 2: The cancer has grown deeper into the esophagus and may have spread to nearby lymph nodes.
- Stage 3: The cancer has spread even further, possibly to more lymph nodes or nearby tissues.
- Stage 4: This is the most advanced stage. The cancer has spread to distant organs, like the liver, lungs, or bones.
Esophageal cancer treatment
AHN Cancer Institute offers comprehensive treatment for esophageal cancer. We emphasize a multidisciplinary approach to create comprehensive and individualized treatment plans for your needs.
Surgery
Surgery is generally an option for earlier-stage cancers that are localized to the esophagus and surrounding tissues. AHN surgeons strive to use minimally invasive techniques (laparoscopic or robotic surgery) when appropriate, which can lead to smaller incisions, less pain, and faster recovery. Surgical approaches include:
- Esophagectomy: The main surgical procedure involves removing part or all of the esophagus, along with nearby lymph nodes. Types of esophagectomy treatments include:
- Transthoracic esophagectomy (Ivor Lewis): The most common approach. Involves small incisions on the abdomen and chest. Part of the stomach is pulled up into the chest to replace the removed esophagus.
- Transhiatal esophagectomy: Involves incisions on the abdomen and neck. The esophagus is removed through these incisions without opening the chest.
- Lymph node dissection: An important part of the surgery. Removing lymph nodes helps determine if the cancer has spread and reduces the risk of recurrence.
- Reconstruction: After the esophagus is removed, a new passage is created to connect the remaining esophagus to the stomach. This is usually done by pulling a portion of the stomach up into the chest or neck to replace the removed esophagus. In rare cases, a section of the colon may be used. The goal of reconstruction is to maintain the ability to eat and drink without a feeding tube.
Chemotherapy
Chemotherapy uses specific, targeted drugs to kill cancer cells throughout the body. AHN oncologists determine which type of chemotherapy will work best for your prognosis. The different types of chemotherapy that may be used include:
- Neoadjuvant chemotherapy: Given before surgery to shrink the tumor and make it easier to remove. May also improve the chance of long-term survival.
- Adjuvant chemotherapy: Given after surgery to kill any remaining cancer cells and reduce the risk of recurrence.
- Chemotherapy for advanced cancer: Used to control the growth of the cancer and relieve symptoms in patients with metastatic (spread to distant sites) disease.
- Common chemotherapy drugs include:
- Cisplatin
- Oxaliplatin
- 5-Fluorouracil (5-FU)
- Leucovorin (folinic acid)
- Capecitabine
- Paclitaxel
- Docetaxel
- Irinotecan
Radiation therapy
Radiation therapy uses high-energy rays to kill cancer cells. It can be given before or after treatment and often at the same time as chemotherapy. AHN uses the latest radiation technologies to focus the treatment to the affected area.
Types of radiation therapy includes:
- External Beam Radiation Therapy (EBRT): Radiation is delivered from a machine outside the body.
- Brachytherapy (Internal Radiation Therapy): Radioactive seeds or sources are placed directly into or near the tumor. Less commonly used for esophageal cancer.
Radiation therapy can cause side effects, including:
- Fatigue
- Skin irritation (like a sunburn)
- Difficulty swallowing (esophagitis)
- Nausea
- Narrowing of the esophagus (stricture)
- Lung damage (pneumonitis)
- Heart problems
Chemoradiation
A combination of chemotherapy and radiation therapy given concurrently. It can be given as the only form of treatment or before or after surgery. Chemoradiation can cause more severe side effects than either chemotherapy or radiation therapy alone.
Targeted therapy
Targets specific molecules or pathways involved in cancer cell growth and survival. Typically used for advanced esophageal cancer. Side effects vary depending on the specific targeted therapy used. When it's used: Examples of Targeted Therapies:
- Trastuzumab (Herceptin): Targets the HER2 protein, which is overexpressed in some esophageal adenocarcinomas.
- Ramucirumab (Cyramza): Targets the VEGFR2 protein, which is involved in blood vessel growth.
Immunotherapy
The goal of this treatment is to boost the body's immune system to fight cancer. Primarily used for advanced esophageal cancer, especially if the cancer cells have certain characteristics (e.g., high PD-L1 expression, microsatellite instability-high (MSI-H), claudin proteins).
Examples of immunotherapy drugs include Pembrolizumab (Keytruda) and Nivolumab (Opdivo). Immunotherapy can be given with chemotherapy or as a single therapy depending on the nature of the cancer.
Immunotherapy can cause immune-related side effects, such as:
- Fatigue
- Skin rash
- Diarrhea
- Pneumonitis
- Hepatitis thyroid problems
Endoscopic therapies
These are minimally invasive techniques used to treat very early-stage esophageal cancer and precancerous conditions, primarily targeting abnormalities in the inner lining of the esophagus. Endoscopic therapies are generally less invasive than surgery (esophagectomy) and can often be performed on an outpatient basis. It is often used for very early-stage cancers or precancerous conditions (Barrett's esophagus). Endoscopic therapy options include:
- Endoscopic Mucosal Resection (EMR): Used to remove early-stage cancers that are limited to the inner lining of the esophagus.
- Radiofrequency Ablation (RFA): Uses heat to destroy abnormal cells in Barrett's esophagus and early-stage esophageal cancer.
- Photodynamic Therapy (PDT): A light-sensitive drug is injected into the bloodstream, and then a laser is used to activate the drug and destroy cancer cells. This therapy is most often used to help treat difficulty swallowing from esophageal tumors.
- Esophageal stent placement: A metal tube is inserted into the esophagus to keep it open if there is blockage from a tumor. Primarily used to relieve symptoms and improve swallowing in patients with advanced cancer.
Palliative care
The focus is to relieve symptoms and improving the quality of life for patients with advanced esophageal cancer. Management focuses Includes:
- Pain management
- Nutritional support
- Management of swallowing difficulties
- Emotional and psychological support
No matter the treatment you undergo, your AHN care team will monitor any side effects and your overall health and well-being through the process. Your treatment plan will be tailored to your specific health needs and goals. AHN sees you and your unique needs first, and we are focused on delivering individualized care that delivers results.
Esophageal cancer FAQs
If you are at greater risk for esophageal cancer or if you have been recently diagnosed, you will likely have questions. Your AHN care team is here to help you get answers and feel more confident in your care plan. In the meantime, we’ve included some frequently asked questions that patients often have to give you background information that may help in the conversations with your care team.
Is cancer of the esophagus curable?
The possibility of curing esophageal cancer depends on several factors, including the stage at diagnosis, the type of esophageal cancer, the patient's overall health, and the treatment approach. If the cancer is found early, when it is small and hasn't spread, the chances of a cure are higher. Treatment options like surgery, chemotherapy, immunotherapy, and radiation therapy can be used alone or in combination to try to eliminate the cancer. However, even if a cure isn't possible, treatments can still help to manage the disease, relieve symptoms, and improve quality of life.
Does esophageal cancer spread fast?
The rate at which esophageal cancer spreads can vary. In some cases, it may spread slowly, while in others, it can be more aggressive. The stage and grade of the cancer, as well as individual patient factors, can influence the speed of its spread. Regular monitoring and follow-up appointments are essential to detect any signs of progression or recurrence.
What are symptoms of stage 1 esophageal cancer?
In the early stages, such as stage 1, esophageal cancer may not cause any noticeable symptoms. When symptoms do appear, they can be subtle and easily mistaken for other conditions. Some potential symptoms of esophageal cancer include:
- Difficulty swallowing (dysphagia): This may start as a feeling that food is getting stuck
- Indigestion or heartburn: Persistent indigestion or heartburn that doesn't respond to typical treatments.
- Chest pain or discomfort: Some people may experience pain or discomfort in the chest.
- Unexplained weight loss: A small amount of unexplained weight loss may occur.
- Cough or hoarseness: Less commonly, a persistent cough or hoarseness may be present.
- Changes in stool color: Black stool can indicate bleeding. This may be more common if you are on a blood thinning medication.
Is esophageal cancer aggressive?
Esophageal cancer can be an aggressive disease, particularly if it is not detected and treated early. Certain types of esophageal cancer, such as squamous cell carcinoma, may be more aggressive than others. The aggressiveness of the cancer can also depend on factors like the grade of the cancer cells and whether it has spread to nearby lymph nodes or other parts of the body.
Contact us
Call the Hope Line at (412) 578-HOPE (412) 578-4673 to connect with a nurse navigator or schedule an appointment.
Second opinions
If you have cancer, you have a team of oncology specialists ready to review your medical records and offer you a second opinion. After completing their review, they’ll talk with you about your goals to determine a course of treatment that’s right for you. To get started, fill out our Second Opinion Request form. A nurse navigator will contact you within the next 24 to 48 hours to discuss next steps and schedule