Esophageal Cancer

According to the American Cancer Society, more than 16,000 Americans are diagnosed with esophageal cancer each year. It affects men much more often than women. Middle-aged men who are overweight with a history of acid reflux (heartburn) seem to be at the highest risk. 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.

The esophagus is a foot-long tube that carries food and liquids from the mouth to the stomach. Its lining has several layers. Esophageal cancer begins in the cells of the 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, and it is a pre-malignant condition which can become esophageal cancer, and needs to be watched closely.

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.

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.

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.