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Esophageal cancer develops in the esophagus, a muscular organ that carries swallowed food and liquids through the throat and into the digestive tract. In most cases, the tumor begins in the organ’s moist inner lining (mucosa).

Cancer that originates in the esophagus is relatively uncommon, accounting for approximately 1% of cancer diagnoses in the United States.

Esophageal cancer types

Esophageal cancer is categorized based on its cellular origin. The main types are:

Squamous cell carcinoma – Forms in the thin, flat cells in the esophageal lining, usually in the upper two-thirds of the esophagus near the throat
Adenocarcinoma – Forms in the mucus-producing glandular cells in the esophageal lining, usually in the lower third of the esophagus near the stomach

Esophageal cancer causes

Scientists have linked esophageal cancer to damaged deoxyribonucleic acid (DNA) in the mucosal cells that line the esophagus. DNA contains oncogenes and tumor suppressor genes, which control cellular function and provide instructions on when cells should replicate and die. Oncogenes instruct cells to grow and survive, while tumor suppressor genes instruct cells to stop growing and die at the appropriate time.

Damaged DNA can inadvertently “turn on” oncogenes or “turn off” tumor suppressor genes. This can cause cells to grow rapidly and live beyond their normal lifespan, leading to an overabundance of cells. The excess cells may then bind together and form tumors.

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Esophageal cancer risk factors

A DNA segment carrying genetic information

Certain acquired and inherited traits can affect the integrity of the cellular DNA in the esophageal mucosa and increase the risk of cancer. The primary risk factor for esophageal cancer is chronic irritation and inflammation of the esophageal lining, which can result from:

Gastroesophageal reflux disease (GERD) – Persistent acid reflux can damage the esophageal lining.
Barrett’s esophagus – Sometimes associated with long-term GERD, this precancerous condition can cause cellular changes in the esophageal lining.
Achalasia – A swallowing disorder, achalasia occurs when the muscles in the lower esophagus fail to relax, preventing food from passing into the stomach.
Plummer-Vinson syndrome – In addition to iron-deficiency anemia, this rare condition can cause web-like fibrous growths in the throat that interfere with swallowing.

Other risk factors for esophageal cancer include:

Esophageal trauma – A direct blow or other injury to the esophagus
Exposure to cancer-causing substances – Sustained contact with chemical carcinogens, such as acetaldehyde and polycyclic aromatic hydrocarbons, or environmental carcinogens, such as silica and asbestos
Certain habits – Smoking and excessive consumption of alcoholic beverages, maté or very hot liquids
Nutritional deficiencies – A vitamin or mineral imbalance or insufficient intake of fruits or vegetables
Certain medications – Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) or H2-receptor antagonists
Obesity – Excess body weight or fatty tissue, especially when carried around the abdomen

Esophageal cancer symptoms

Esophageal cancer tends to grow slowly and may not produce noticeable symptoms for many years. Often, the first warning sign is difficulty swallowing (dysphagia) due to coughing or choking or a sensation that food is lodged in the throat.

In addition to dysphagia, other signs of esophageal cancer can include:

Pain or burning behind the breastbone
Heartburn
Indigestion
Decreased appetite
Unexplained weight loss
Bloody stool (caused by esophageal bleeding)
A lump under the chest skin

If esophageal cancer spreads beyond the esophagus, it may cause other symptoms, such as:

Hiccups
Chronic vocal hoarseness
Persistent coughing
Back pain
Hypercalcemia and bone pain
Respiratory fistulas

Esophageal cancer diagnostic testing

The diagnostic process for esophageal cancer usually begins with an imaging test, such as an upper gastrointestinal study with barium swallow (esophagram). Before X-rays are taken, the patient will be asked to swallow some barium, a harmless chalky liquid that will coat the inner walls of the esophagus to enhance image clarity. Other imaging technologies, such as magnetic resonance imaging (MRI), computed tomography (CT) with contrast and positron emission tomography (PET), may be used as well.

In medical images, early-stage esophageal cancer may look like small round bumps or raised flat areas (plaques) in the esophagus, while advanced-stage esophageal cancer may look like a large, irregular or narrowed area. If esophageal cancer is suspected based on initial testing, the diagnostic process may continue with:

Esophagoscopy – A physician will guide a thin, flexible tube with a light source and miniature camera attached (endoscope) down the throat and into the esophagus. Using the endoscope, the physician will capture high-resolution images that will be displayed on an external monitor in real time, allowing the physician to visualize the interior of the esophagus.
Biopsy – During an esophagoscopy or another endoscopic procedure, the physician will pass a special instrument through the endoscope to collect a sample of esophageal tissue for microscopic examination by a pathologist, who can identify cancerous cells.
Blood testing – A complete blood count (CBC) can detect a lower-than-normal red blood cell count (anemia), which may result from a bleeding esophageal tumor. A liver enzyme test can check the function of the liver, which may be affected by metastatic esophageal cancer.

If a diagnosis of esophageal cancer is confirmed, the physician may order further testing to determine if and how far the cancer has spread. Known as staging, this process can provide valuable information to guide treatment decisions.

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Esophageal cancer stages

When staging an esophageal tumor, many physicians use the American Joint Committee on Cancer (AJCC) TNM system, which considers three key factors: the size of the primary tumor (T), lymph node involvement (N) and cancer metastasis (M).

The stages of esophageal cancer are:

Stage 0 – Noncancerous but abnormal esophageal cells (high-grade dysplasia) are found in the esophagus.
Stage 1 – Cancerous cells have grown into the inner lining of the esophageal wall.
Stage 2 – Cancerous cells have spread into the main muscular layer of the esophagus.
Stage 3 – Cancerous cells have penetrated the outer wall of the esophagus and invaded nearby lymph nodes or organs.
Stage 4 – Cancerous cells have metastasized to distant lymph nodes or organs.

Esophageal cancer treatment

The treatment options for esophageal cancer may include:

Surgery

The most common surgical treatment for esophageal cancer is esophagectomy, which involves removing all or a portion of the esophagus, some nearby lymph nodes and a portion of the stomach. If the esophagus is completely removed, the surgeon may use a section of the stomach or large intestine to create a passageway for food. If the esophagus is partially removed, the surgeon may reposition the remaining part of the stomach in the chest or neck and connect it to the remaining part of the esophagus. Until swallowing function is restored, a feeding tube may be temporarily used to deliver nutrition directly to the stomach.

Radiation therapy

Radiation therapy involves the precise delivery of high-energy X-rays or particles directly to a tumor to destroy cancerous cells. The treatment may be administered before surgery to shrink a tumor and make it easier to remove, after surgery to target any remaining microscopic cancer cells or as a main form of treatment if surgery is not feasible. For enhanced effectiveness, radiation therapy is sometimes combined with chemotherapy, a treatment approach known as chemoradiation.

Chemotherapy

Chemotherapy is a systemic treatment that uses powerful cancer-fighting drugs, which may be swallowed or injected into a vein. After entering the bloodstream, the drugs circulate throughout the body to reach widespread cancer cells that have spread or metastasized beyond the esophagus. Chemo is usually administered in cycles, with each treatment cycle followed by a break to allow the body time to recover. Usually, chemotherapy cycles span two to four weeks, and many patients receive several cycles of treatment.

Frequently asked questions (FAQs) about esophageal cancer

The following FAQs-related articles provide additional information about esophageal cancer:

Benefit from world-class care at Moffitt Cancer Center

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The multispecialty team in Moffitt’s renowned Gastrointestinal Oncology Program offers the latest treatment options for esophageal cancer, including esophagectomy and other surgical procedures performed with the robotic assistance of the da Vinci® Surgical System. We also offer radiation therapy specifically for gastrointestinal cancers, chemoradiation and novel chemotherapy regimens through our robust portfolio of clinical trials.

If you would like to learn more about esophageal cancer, you can request an appointment with a specialist in our Gastrointestinal Oncology Program by calling 1-888-663-3488 or submitting a new patient registration form online.