The esophagus is a foot-long tube that carries food and liquids from the mouth to the stomach. Esophageal cancer begins in the cells of the esophagus’ inside lining. It then grows into the channel of the esophagus and the esophageal wall.
A sphincter, a special muscle that relaxes to let food in or out, is on each end of the esophagus. The one at the top lets food or liquid into the esophagus. The one on the bottom lets food enter the stomach.
This sphincter also prevents stomach contents from going back into the esophagus. If stomach juices with acid and bile come into the esophagus, it causes indigestion or heartburn. Reflux and gastroesophageal reflux disease (GERD) are the medical names for heartburn.
If you have reflux for a long time, the cells at the end of the esophagus change to become more like the cells in the intestinal lining. This is called Barrett’s esophagus. It is a pre-malignant condition that can become esophageal cancer and needs to be watched closely.
According to the American Cancer Society, more than 16,000 Americans are diagnosed with esophageal cancer each year. Because the disease often has no symptoms in the early stages, it is usually detected at a more advanced stage that is more challenging to treat.
Esophageal Cancer Types
The types of esophageal cancer are named after the cells where they begin.
Adenocarcinoma is the most common type of esophageal cancer in western societies, especially in white males. It starts in gland cells in the tissue, most often in the lower part of the esophagus near the stomach. The major risk factors include reflux and Barrett’s esophagus.
Squamous cell carcinoma or cancer, also called epidermoid carcinoma, begins in the tissue that lines the esophagus, particularly in the middle and upper parts. In the United States, this type of esophageal cancer is on the decline. Risk factors include smoking and drinking alcohol.
This is the most common type of esophageal cancer worldwide. In other countries, including Iran, northern China, India and southern Africa, this type of esophageal cancer is much more common than in the United States.
The best thing you can do to prevent esophageal cancer is to not smoke or drink too much alcohol. Visit our prevention and screening section to learn how to manage your risk.
Esophageal Cancer Risk Factors
Anything that increases your chance of getting esophageal cancer is a risk factor. Long-term heartburn or reflux is a factor in half of esophageal cancers. Other esophageal cancer causes and risks include:
- Long-term history of smoking: Half of squamous cell esophageal cancers involve smoking. Smoking also increases the risk of adenocarcinoma.
- Drinking too much alcohol, especially if you smoke
- Barrett's esophagus, a condition in which chronic acid reflux causes changes in the cells lining the lower esophagus
- Age: Most cases of esophageal cancer are in people over 55.
- Gender: Men are three times more likely than women to develop esophageal cancer.
- Achalasia, a disease in which the sphincter, or muscle, at the bottom of the esophagus fails to open and move food into the stomach
- Tylosis, a rare, inherited disorder that causes excess skin to grow on the soles of the feet and palms. It has a near 100% chance of developing into esophageal cancer.
- Esophageal webs: These flaps of tissue protrude into the esophagus, making swallowing difficult
- Lye ingestion or being around dry-cleaning chemicals
- Diet and weight: Risk is higher if you are overweight, tend to overeat or do not eat a healthy diet
- History of other squamous cell cancers related to tobacco use
Not everyone with risk factors gets esophageal cancer. However, if you have risk factors, you should discuss them with your doctor.
What are the symptoms of esophageal cancer?
Signs of esophageal cancer are often not apparent in its early stages. If you have symptoms, they may include:
- Indigestion and heartburn
- Difficult or painful swallowing (dysphagia)
- Pain, pressure or burning in the throat or chest
- Weight loss, less appetite
- Black tar-like stools
- Anemia
- Vomiting
- Hoarseness
- Persistent hiccups
- Chronic cough
- Pneumonia
- High levels of calcium in the blood
These symptoms do not always mean you have esophageal cancer. However, it is important to discuss any symptoms with your doctor, since they may signal other health problems.
How is esophageal cancer diagnosed?
MD Anderson's experts use the most advanced technology and techniques to pinpoint esophageal cancer. Precise diagnosis often improves your chances for successful treatment. Since esophageal cancer often does not have symptoms in early stages, it may be found during procedures or tests for other conditions.
Esophageal Cancer Diagnostic Tests
If you have symptoms that may signal esophageal cancer, your doctor will examine you and ask you questions about your health; your lifestyle, including smoking and drinking habits; and your family medical history.
One or more of the following tests may be used to find out if you have esophageal cancer and if it has spread. These tests also may be used to find out if treatment is working.
Imaging tests, which may include:
- X-rays
- CT or CAT (computed axial tomography) scans
- MRI (magnetic resonance imaging) scans
- PET (positron emission tomography) scans
Biopsy
One of the following methods may be used to biopsy tissue to find out if you have esophageal cancer:
Esophagoscopy: An endoscope is inserted through the mouth or nose into the esophagus. The doctor looks at the esophagus and removes small pieces of tissue.
Endoscopic ultrasound (EUS) or endosonography: An endoscope is inserted through an opening in the body, usually the mouth or rectum. At the end of the tube are a light, a tiny camera and a device that sends out ultrasound (high-energy sound) waves to make images of internal organs.
Video endoscopy: An endoscope with a special fiber-optic camera is inserted through the mouth, allowing the doctor to view the esophagus and biopsy the suspicious area.
Bronchoscopy: Using a tool called a bronchoscope, which is similar to the endoscope, the doctor looks at the trachea (windpipe) and the tubes that go into the lungs.
Laryngoscopy: With a tool called a laryngoscope, which is similar to the endoscope, the doctor examines the larynx (voice box).
Thoracoscopy: A small incision is made between two ribs, and an instrument called a thoracoscope is inserted through it into the chest. The thoracoscope is similar to the endoscope. It lets the doctor view and biopsy the lymph nodes inside the abdomen and chest.
Esophageal Cancer Staging
(source: National Cancer Institute)
The most common system used to stage esophageal cancer is the TNM system of the American Joint Committee on Cancer (AJCC).
The TNM system describes three key pieces of information:
- T refers to the size of the primary tumor and how far it has spread within the esophagus and to nearby organs
- N refers to cancer spread to nearby lymph nodes
- M indicates whether the esophageal cancer has metastasized (spread to distant organs)
Staging also takes into account the cell type of the cancer and the grade of the cancer.
Esophageal Cancer Stages
T Stages
- Tis: The cancer is only in the epithelium (the top layer of cells lining the esophagus). It has not started growing into the deeper layers. This stage also is known as high-grade dysplasia. In the past it was called carcinoma in situ.
- T1: The cancer is growing into the tissue under the epithelium, such as the lamina propria, muscularis mucosa or submucosa
- T2: The cancer is growing into the muscle layer (muscularis propria)
- T3: The cancer is growing into the outer layer of tissue covering the esophagus (the adventitia)
- T4: The cancer is growing into nearby structures
- T4a: The cancer is growing into the pleura (the tissue covering the lungs), the pericardium (the tissue covering the heart), or the diaphragm. The cancer can be removed with surgery.
- T4b: The cancer cannot be removed with surgery because it has grown into the trachea (windpipe), aorta, spine or other crucial structures.
N Stages
- N0: The cancer has not spread (metastasized) to nearby lymph nodes
- N1: The cancer has spread to one or two nearby lymph nodesN2: The cancer has spread to three to six nearby lymph nodes
- N3: The cancer has spread to seven or more nearby lymph nodes
M Stages
- M0: The cancer has not spread (metastasized) to distant organs or lymph nodes
- M1: The cancer has spread to distant lymph nodes and/or other organs
Grade
The grade of a cancer is based on how normal (or differentiated) the cells appear when they are looked at under the microscope. The higher the number, the more abnormal the cells look. Higher-grade tumors tend to grow and spread faster than lower-grade tumors.
- GX: The grade cannot be assessed (treated in stage grouping as G1)
- G1: The cells are well differentiated
- G2: The cells are moderately differentiated
- G3: The cells are poorly differentiated
- G4: The cells are undifferentiated (these cells are so abnormal that doctors can't tell if they are adenocarcinoma or squamous cell carcinoma). For staging, G4 cancers are grouped with G3 squamous cell cancers.
Location
Some staging of early squamous cell esophageal cancer also takes into account where the tumor is in the esophagus. The location is upper, middle or lower based on the location of the upper edge of the tumor.
What are the treatment options for esophageal cancer?
Studies have shown that people have better outcomes in cancer programs that treat a high level of patients. We have one of the most active esophageal cancer programs in the nation.
We offer many innovative treatments for esophageal cancer, including minimally invasive surgeries, photodynamic therapy, targeted therapies and endoscopic surgery for early stage disease. In addition, our status as a major research site allows us to offer a full range of clinical trials for esophageal cancer.
If you are diagnosed with esophageal cancer, your doctor will discuss the best options to treat it. This depends on several factors, including the type and stage of the cancer and your general health. Your treatment for esophageal cancer will be customized to your particular needs. One or more of the following therapies may be recommended to treat the cancer or help relieve symptoms.
Surgery
This is the most common treatment for esophageal cancer that has not spread to the lymph nodes. The procedure most often performed is an esophagectomy, and there are several methods to perform it. Your doctor will recommend the best technique for you based on the location of the tumor and if it has spread.
Generally, the surgery includes removal of:
- All or part of the esophagus
- Part of the stomach
- Lymph nodes that are close to the esophagus
The remaining stomach is pulled up into the chest or neck and connected to the remaining esophagus. You may need a feeding tube (a small tube that is inserted into the nose or mouth and into the stomach) until you are able to eat.
Side effects of the surgery may include:
- Leaking at the site where the stomach and esophagus are joined. This may mean the stomach empties slowly, causing nausea and vomiting.
- Trouble swallowing: An upper endoscopy to stretch passages may help
- Heartburn
- Digestive problems: You may be able to eat only small amounts of food at a time
To treat more-advanced stages of esophageal cancer, surgery may be combined with chemotherapy and/or radiation therapy.
Radiation Therapy
New radiation therapy techniques and remarkable skill allow MD Anderson doctors to target tumors more precisely, delivering the maximum amount of radiation with the least damage to healthy cells.
MD Anderson provides the most advanced radiation treatments for esophageal cancer, including:
- Brachytherapy: Tiny radioactive seeds are placed in the body close to the tumor
- 3D-conformal radiation therapy: Several radiation beams are given in the exact shape of the tumor
- Intensity-modulated radiotherapy (IMRT): Treatment is tailored to the specific shape of the tumor
Proton Therapy
Proton therapy delivers high radiation doses directly to the tumor site, with no damage to nearby healthy tissue. For some patients, this therapy results in better cancer control with fewer side effects. MD Anderson's Proton Therapy Center treats some esophageal cancers.
Chemotherapy: MD Anderson offers the most up-to-date and advanced chemotherapy options for esophageal cancer.
Photodynamic therapy (PDT): Laser-sensitive chemicals are injected into the esophageal cancer site. A laser beam then targets the chemicals to destroy the tumor. It may also be used to treat Barrett's esophagus or to help if a tumor is blocking the esophagus but cannot be treated with other methods.
Endoscopic mucosal resection (EMR): This minimally invasive technique may be used if the cancer is small and only on the surface of the esophagus. A needle is placed in the esophageal wall, and then saline (saltwater) is injected to make a bubble under the growth. Using suction, the lesion is removed.
Esophageal stents: Small, expandable metal or plastic tubes are placed over the tumor with the aid of an endoscope. Once placed, the stent can expand and open up the blocked part of the esophagus, allowing food and liquids to pass through easier.
Electrocoagulation: Electricity is used to burn off the tumor.
Targeted therapies: These innovative drugs stop the growth of esophageal cancer cells by interfering with certain proteins and receptors or blood vessels that allow the tumor to grow.
Why come to MD Anderson for your esophageal cancer care?
Studies have shown a link between the number of patients treated and successful outcomes, and we have one of the most active programs in the nation. You re followed by a team of highly specialized physicians and support specialists - all with extensive experience in esophageal cancer care. We are especially proud of our minimally invasive surgery capabilities, including an endoscopic mucosal resection program for patients with very early stage esophageal cancer. Minimally invasive procedures often are able to preserve the function of the esophagus and stomach and avoid the need for radical surgery. This allows you to retain higher levels of function and quality of life.
We're often able to provide hope for advanced esophageal cancer that might not be available elsewhere, including therapies that deliver maximum effectiveness with the least impact on your body.
As one of the world's largest cancer research centers, MD Anderson is leading investigation into new methods of esophageal cancer diagnosis and treatment. You benefit from the most advanced research, conducted by some of the nation's top scientists.
Cancer is serious. And I am seriously determined to get well.
With a family history of colon cancer, Brian Folloder has been getting regular colonoscopies since he turned 35. But in 2009, when he was 62 years old, a screening blood test for medical insurance showed a possible sign of cancer. So, Brian had a CT scan.
It showed no evidence of cancer. Yet, Brian’s son Justin, a physician assistant in Surgical Oncology at MD Anderson, insisted Brian get a six-month follow-up scan at MD Anderson.
The scan revealed Brian had a pancreatic neuroendocrine tumor that would require surgery.
“My son just kept telling me, ‘Dad, you’re going to be fine.’” Brian says. And Justin was mostly right.
Finding life through surgery at MD Anderson
When Brian arrived at MD Anderson for surgery, he was scared. “I was crying like a baby because I thought people came here to die,” he says.
Brian quickly found the opposite to be true.
After a nearly eight-hour surgery with Jason B. Fleming, M.D., to remove the tumor, his gallbladder and lymph nodes, Brian was pancreatic cancer-free. But he would need to be followed for Barrett’s esophagus, a condition that made him more likely to develop esophageal cancer. The condition was incidentally discovered during the biopsy of his pancreas.
“My care was managed by an amazing team of doctors. And you know what they did?” Brian says. “They gave me more time to live.”
A second round of cancer
In September 2010, Brian had an endoscopy as part of his surveillance under gastroenterologist Jeffrey H. Lee, M.D. It showed cancer. Following a biopsy, Brian was diagnosed with esophageal adenocarcinoma.
Wayne Hofstetter, M.D., director of MD Anderson’s Esophageal Surgery Program, was consulted for Brian’s care. “He was thorough,” Brian says. “He presented me with two treatment options and was clear that the choice was mine.”
Brian could opt for a novel technique known as endoscopic mucosal resection, which allowed Dr. Hofstetter to preserve his esophagus. The procedure uses an endoscope with an attached device to reach and then remove the tumors. The alternative option was an esophagectomy – surgery to remove part of his esophagus.
“Choosing between the two was not an easy decision,” Justin says.
Choosing endoscopic mucosal resection surgery
An endoscopic mucosal resection would require aggressive surveillance post-procedure – serial endoscopies and scans for an indefinite amount of time. “This can be a bit riskier for managing the disease,” Justin explains. “An esophagectomy is a more aggressive approach to remove the cancer, but causes permanent lifestyle changes and has its own set of risks.”
Brian made his decision after connecting with other patients through myCancerConnection, MD Anderson’s one-on-one support program for patients and caregivers. After speaking with four patients, Brian says he found his cure.
He choose an endoscopic mucosal resection, followed by serial radiofrequency ablation with Marta Davila, M.D., to manage residual disease.
A new perspective after cancer
Since the endoscopic mucosal resection, Brian has remained cancer-free. “I know not everyone has a success story – my mother died of colon cancer when I was 15 years old,” Brian says. So at 69 years old, with a wife of 25 years, six kids and 10 grandkids, he feels grateful to be alive.
“MD Anderson gave me life -- twice,” Brian says. “And now, I am focused on maintaining a healthy lifestyle and giving back.”
