November 10, 2020
10 things to know about esophageal cancer
BY Cynthia DeMarco
Updated June 1, 2022
More than 16,000 people in the United States will be diagnosed with esophageal cancer this year. Roughly 75% of those will be men.
So, what esophageal cancer symptoms should you watch for? How is esophageal cancer diagnosed, and what treatments are available?
To get answers to these questions and more, we spoke with Wayne Hofstetter, M.D., a thoracic surgeon who specializes in esophageal cancer.
How is esophageal cancer typically diagnosed?
We usually diagnose esophageal cancer in one of two ways. The first is because someone is showing symptoms. About 75% of our esophageal cancer patients do. The second is because someone is already under surveillance for another reason — such as acid reflux — and the cancer is found incidentally during a scan or a scoping procedure.
When someone has symptoms of esophageal cancer, the first thing we’ll do is examine them and ask some questions. Then, we’ll either order a scan (such as a CT or a PET) or schedule an endoscopic procedure (in which a scope is used to look inside the body) to help us determine if they have it. Many endoscopic procedures will also involve a biopsy, in which small samples of suspicious tissue are removed for analysis in a lab.
What are the most common esophageal cancer symptoms?
Most of our patients complain of dysphagia, or trouble swallowing. Some report having chest pain or issues with obstruction and regurgitation.
But these aren’t the only symptoms people can have. Others include weight loss, tarry stools, anemia and coughing or hoarseness.
What are the most common types of esophageal cancer?
Adenocarcinoma makes up the majority of esophageal cancer cases in the United States — about 85%. Those generally develop in the lower portion of the esophagus, where it connects to the stomach.
Squamous cell carcinoma is much less common here. It generally develops in the middle and upper regions of the esophagus.
Esophageal cancer affects three times as many men than women. Why is that?
This is not currently completely understood. With esophageal adenocarcinoma, there is a correlation to body habitus (overweight and large belly), reflux and eating habits. Yet, there is not a clear reason for the differences in affliction between the sexes.
On the other hand, squamous cancers are associated with different lifestyle choices, such as smoking and drinking alcohol. These risk factors may be more prevalent in men compared to women.
How is esophageal cancer typically treated?
When the cancer is only in the esophagus itself and perhaps some nearby lymph nodes, we typically combine different types of treatments to get the best results. Options include chemotherapy and surgery; or a combination of chemotherapy, radiation therapy and surgery. Sometimes it’s also treated with immunotherapy combined with other therapies, like chemotherapy. For advanced cancers, immunotherapy is becoming standard of care. In May 2022, the FDA approved two immunotherapy combinations for first-line treatment of advanced or metastatic esophageal squamous cell carcinoma that can’t be removed with surgery, based on results from the international Phase III CheckMate -648 trial, which was co-led by Jaffer Ajani, M.D. In early cancer, immunotherapy looks promising, and several recent experimental trials have shown encouraging results.
For patients with more advanced disease, molecular markers often come into play. So, we test tumors to see if they have specific genetic markers. Then, we can make decisions about which targeted therapies might be most effective, such as trastuzumab (Herceptin). When it comes to the recent immunotherapy approval for advanced cancer, the anti- PD-L1 checkpoint inhibitor nivolumab is approved in combination with chemotherapy or ipilimumab, a different checkpoint inhibitor, regardless of the patient’s PD-L1 status.
What are some of the latest advances in esophageal cancer treatment?
The most exciting development in the field of esophageal cancer is probably the personalization of treatment. We’re not using the exact same tools to treat every single patient.
MD Anderson has pioneered a number of organ-sparing therapies for esophageal cancer treatment. But in patients with early-stage esophageal cancer, we can now do endoscopic resections — or removal of the cancerous lesions through scope-based procedures — without ever performing surgery. That means quicker recovery times for patients because we don’t have to cut into healthy tissue to reach the cancer.
For patients in the intermediate stages of esophageal cancer, we can sometimes just do surgery alone. And if patients with locally advanced disease respond well to chemotherapy and radiation, they might not require surgery to remove their esophagus.
What clinical trials are available for patients with esophageal cancer?
We have several clinical trials for esophageal cancer. One ongoing trial is recruiting patients with locally advanced disease who appear to have curable disease. In this clinical trial, we are looking at the effectiveness of adding immunotherapy to standard chemotherapy, followed by surgery. We already know that immunotherapy can train a patient’s own immune system to attack many types of cancer. So, we’re hoping to see how active the immune system can be against a potentially curable esophageal cancer.
Another trial is looking at the effectiveness of adding early local therapies, such as chemoradiation, surgery or both, for patients with advanced oligometastatic esophageal cancer. These patients have disease that has limited spread to other areas of the body and were previously considered incurable. With better individualized therapy, we are seeking to improve survival and potentially even cure patients in these situations.
Why is it important for patients to go to a cancer center like MD Anderson for their esophageal cancer treatment?
At MD Anderson, treating cancer is not just part of our job. It is our job. So, even if a particular technique or treatment was not invented here at MD Anderson, we are going to know about it. And we are going to be aware of everything else that’s going on in the field and what’s going to give our patients the best possible outcome.
Also, our radiation oncologists who specialize in esophageal cancer are going to be focused specifically on that particular disease. So are our surgeons, oncologists and pathologists. That means you’ll have a team of experts who focus only on your specific type of cancer and have treated hundreds, if not thousands, of cases.
What’s the most important thing that newly diagnosed esophageal cancer patients and their caregivers should know?
The first place you go for esophageal cancer treatment is critically important. Because a lot of technologies are operator-dependent. That means it’s vital to seek care from experts with extensive experience in interpreting test results and formulating treatment plans. You can’t just go to any diagnostic facility in the U.S. for an endoscopy and expect to get the same kind of workup that you would at MD Anderson.
If you’ve already started esophageal cancer treatment somewhere else and your cancer was incorrectly staged, that can adversely affect your results. You run the risk of being over-treated with therapies you might not need, or under-treated because someone underestimated the extent of your disease.
You don’t want to mess around and then find out you’ve done the wrong thing. So, if you’re getting cancer care, you should seek out the best cancer center in the United States from the beginning. That’s MD Anderson. And that’s all there is to it.
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
We’re not using the exact same tools to treat every single patient.
Wayne Hofstetter, M.D.