What is esophageal cancer

Esophageal cancer is cancer that occurs in the esophagus — a long, hollow tube that runs from your throat to your stomach. Your esophagus helps move the food you swallow from the back of your throat to your stomach to be digested.

Esophageal cancer usually begins in the cells that line the inside of the esophagus. Esophageal cancer can occur anywhere along the esophagus. More men than women get esophageal cancer.

Esophageal cancer is the sixth most common cause of cancer deaths worldwide. Incidence rates vary within different geographic locations. In some regions, higher rates of esophageal cancer cases may be attributed to tobacco and alcohol use or particular nutritional habits and obesity.

The American Cancer Society’s estimates for esophageal cancer in the United States for 2018 are:

• About 17,290 new esophageal cancer cases diagnosed (13,480 in men and 3,810 in women)
• About 15,850 deaths from esophageal cancer (12,850 in men and 3,000 in women)

Esophageal cancer is more common among men than among women. The lifetime risk of esophageal cancer in the United States is about 1 in 132 in men and about 1 in 455 in women.

Overall, the rates of esophageal cancer in the United States have been fairly stable for many years, but over the past decade they have been decreasing slightly. It is most common in whites, but is now almost equally as common in African Americans. Adenocarcinoma is the most common type of cancer of the esophagus among whites, while squamous cell carcinomais more common in African Americans. American Indian/Alaska Natives and Hispanics have lower rates of esophageal cancer, followed by Asians/Pacific Islanders.

Esophageal cancer makes up about 1% of all cancers diagnosed in the United States, but it is much more common in some other parts of the world, such as Iran, northern China, India, and southern Africa.

Although many people with esophageal cancer will go on to die from this disease, treatment has improved and survival rates are getting better. During the 1960s and 1970s, only about 5% of patients survived at least 5 years after being diagnosed. Now, about 20% of patients survive at least 5 years after diagnosis. This number includes patients with all stages of esophageal cancer. Survival rates for people with early stage cancer are higher.

The esophagus

The esophagus, a straight, collapsible muscular tube, about 25 cm (10 in.) long, that lies posterior to the trachea. The esophagus is a food passageway from the pharynx to the stomach (see Figure 1). The esophagus begins at the base of the laryngopharynx and descends posterior to the trachea, passing through the mediastinum. It penetrates the diaphragm through an opening, the esophageal hiatus and is continuous with the stomach on the abdominal side of the diaphragm.

Food and liquids that are swallowed travel through the inside of the esophagus (called the lumen) to reach the stomach.

The upper part of the esophagus has a special ring of muscle at its beginning that relaxes to open the esophagus when it senses food or liquid coming toward it. This muscle is called the upper esophageal sphincter.

The lower part of the esophagus that connects to the stomach is called the gastroesophageal (GE) junction. A special ring of muscle near the gastroesophageal junction, called the lower esophageal sphincter, controls the movement of food from the esophagus into the stomach. Between meals, it closes to keep the stomach’s acid and digestive juices out of the esophagus.

Mucous glands are scattered throughout the submucosa of the esophagus. Their secretions moisten and lubricate the tube’s inner lining.

Microscopic Anatomy of the Esophagus

Unlike the mouth and pharynx, the esophagus wall (Figure 2 to 4) contains all four layers of the alimentary canal: mucosa, submucosa, muscularis externa, and adventitia.

The following histological features are of interest:

Mucosa: This layer lines the inside of the esophagus.

The mucosa has 3 parts:

• The mucosal epithelium is the innermost lining of the esophagus and is normally made up of flat, thin cells called squamous cells. At the junction of the esophagus and stomach, this thick, abrasion-resistant layer changes abruptly to the thin simple columnar epithelium of the stomach, which is specialized for secretion (Figure 2). This is where most cancers of the esophagus start.
• The lamina propria is a thin layer of connective tissue right under the epithelium.
• The muscularis mucosa is a very thin layer of muscle under the lamina propria.

Submucosa

• The submucosa of the wall of the esophagus contains mucous glands, primarily compound tubuloalveolar glands, that extend to the lumen. As a bolus passes, it compresses these glands, causing them to secrete a lubricating mucus. This mucus helps the bolus pass through the esophagus.

• When the esophagus is empty, its mucosa and submucosa are thrown into longitudinal folds, but during passage of a bolus, these folds flatten out (Figure 3).

The muscularis externa

• The muscularis externa consists of skeletal muscle in the superior third of the esophagus, a mixture of skeletal and smooth muscle in the middle third, and smooth muscle in the inferior third. This arrangement is easy to remember if the esophagus is viewed as the zone where the skeletal
  muscle of the mouth and pharynx gives way to the smooth muscle of the stomach and intestines.

Adventitia

• The most external esophageal layer is an adventitia, not a serosa, because the thoracic segment of the esophagus is not suspended in the peritoneal cavity.

Figure 1. Esophagus

Figure 2. Esophagus anatomy

Figure 3. Cross section view of the esophagus

Figure 4. Microscopic structure of the esophagus

Esophageal cancer types

Cancer of the esophagus (also called esophageal cancer) starts in the inner layer (the mucosa) and grows outward (through the submucosa and the muscle layer) (see Figure 4). Since 2 types of cells can line the esophagus, there are 2 main types of esophageal cancer:

Squamous cell carcinoma

The esophagus is normally lined with squamous cells. Cancer starting in these cells is called squamous cell carcinoma. This type of cancer can occur anywhere along the esophagus, but is most common in the portion of the esophagus located in the neck region and in the upper two-thirds of the chest cavity. Squamous cell carcinoma used to be the most common type of esophageal cancer in the United States. This has changed over time, and now it makes up less than half of esophageal cancers in this country.

Adenocarcinoma

Cancers that start in gland cells (cells that make mucus) are called adenocarcinomas. This type of cancer usually occurs in the distal (lower third) part of the esophagus. Before an adenocarcinoma can develop, gland cells must replace an area of squamous cells, which is what happens in Barrett’s esophagus. This occurs mainly in the lower esophagus, which is where most adenocarcinomas start.

Adenocarcinomas that start at the area where the esophagus joins the stomach (the GE junction, which includes about the first 2 inches (5 cm) of the stomach called the cardia), tend to behave like cancers in the esophagus (and are treated like them, as well), so they are grouped with esophagus cancers.

Rare cancers

Other types of cancer can also start in the esophagus, including lymphomas, melanomas, and sarcomas. But these cancers are rare and are not discussed further here.

Esophageal cancer causes

It’s not exactly clear what causes esophageal cancer. However, there are certain risk factors that make getting esophageal cancer more likely.

Scientists believe that some risk factors, such as the use of tobacco or alcohol, may cause esophageal cancer by damaging the DNA in cells that line the inside of the esophagus. Long-term irritation of the lining of the esophagus, as happens with reflux, Barrett’s esophagus, achalasia, Plummer-Vinson syndrome, or scarring from swallowing lye, may also lead to DNA damage.

DNA is the chemical in each of our cells that makes up your genes – the instructions for how your cells function. You usually look like your parents because they are the source of your DNA. However, DNA affects more than how you look. Some genes control when cells grow, divide into new cells, and die. Genes that help cells grow, divide, and stay alive are called oncogenes. Genes that slow down cell division or make cells die at the right time are called tumor suppressor genes. Cancers can be caused by DNA changes that turn on oncogenes or turn off tumor suppressor genes.

The DNA of esophageal cancer cells often shows changes in many different genes. However, it’s not clear if there are specific gene changes that can be found in all (or most) esophageal cancers.

Some people inherit DNA changes (mutations) from their parents that increase their risk for developing certain cancers. But esophageal cancer does not seem to run in families, and inherited gene mutations are not thought to be a major cause of this disease.

Esophageal Cancer Risk Factors

A risk factor is anything that changes your chance of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like a person’s age or family history, can’t be changed.

Scientists have found several factors that can affect your risk of esophageal cancer. Some are more likely to increase the risk for adenocarcinoma of the esophagus and others for squamous cell carcinoma of the esophagus.

But having a risk factor, or even many, does not mean that you will get esophageal cancer. And some people who get the disease may not have any known risk factors.

Age

The chance of getting esophageal cancer increases with age. Less than 15% of cases are found in people younger than age 55.

Gender

Men are more likely than women to get esophageal cancer.

Gastroesophageal reflux disease

The stomach normally makes strong acid and enzymes to help digest food. In some people, acid can escape from the stomach up into the lower part of the esophagus. The medical term for this is gastroesophageal reflux disease (GERD), or just reflux. In many people, reflux causes symptoms such as heartburn or pain that seem to come from the middle of the chest. In some, though, reflux doesn’t cause any symptoms at all.

People with GERD have a slightly higher risk of getting adenocarcinoma of the esophagus. This risk seems to be higher in people who have more frequent symptoms. But GERD is very common, and most of the people who have it do not go on to develop esophageal cancer. GERD can also cause Barrett’s esophagus (discussed below), which is linked to an even higher risk.

Barrett’s esophagus

If reflux of stomach acid into the lower esophagus goes on for a long time, it can damage the inner lining of the esophagus. This causes the squamous cells that normally line the esophagus to be replaced with gland cells. These gland cells usually look like the cells that line the stomach and the small intestine, and are more resistant to stomach acid. This condition is known as Barrett’s (or Barrett) esophagus.

The longer someone has reflux, the more likely it is that they will develop Barrett’s esophagus. Most people with Barrett’s esophagus have had symptoms of heartburn, but many have no symptoms at all.

Between 1 and 5 people out of 100 (1–5%) with Barrett’s oesophagus will develop oesophageal cancer. People with Barrett’s esophagus are at a much higher risk than people without this condition to develop adenocarcinoma of the esophagus. Still, most people with Barrett’s esophagus do not get esophageal cancer.

The gland cells in Barrett’s esophagus can become more abnormal over time. This can result in dysplasia, a pre-cancerous condition. Dysplasia is graded by how abnormal the cells look under the microscope. Low-grade dysplasia looks more like normal cells, while high-grade dysplasia is more abnormal. High-grade dysplasia is linked to the highest risk of cancer.

Tobacco and alcohol

The use of tobacco products, including cigarettes, cigars, pipes, and chewing tobacco, is a major risk factor for esophageal cancer. The more a person uses tobacco and the longer it is used, the higher the cancer risk. Someone who smokes a pack of cigarettes a day or more has at least twice the chance of getting adenocarcinoma of the esophagus than a nonsmoker, and the risk does not go away if tobacco use stops. The link to squamous cell esophageal cancer is even stronger, but this risk does go down for people who quit tobacco. .

Drinking alcohol also increases the risk of esophageal cancer. The more alcohol someone drinks, the higher their chance of getting esophageal cancer. Alcohol affects the risk of the squamous cell type more than the risk of adenocarcinoma.

Combining smoking and drinking alcohol raises the risk of esophageal cancer much more than using either alone.

Obesity

People who are overweight or obese (very overweight) – obesity means being very overweight with a body mass index (BMI) of 30 or higher — have a higher chance of getting adenocarcinoma of the esophagus. Being overweight or obese is linked to more than 1 in 4 oesophageal cancers in men and more than 1 in 10 in women. The more overweight you are the higher the risk. This is in part explained by the fact that people who are obese are more likely to have gastroesophageal reflux.

Diet

Certain substances in the diet may increase esophageal cancer risk. For example, there have been suggestions, as yet not well proven, that a diet high in processed meat may increase the chance of developing esophageal cancer. This may help explain the high rate of this cancer in certain parts of the world.

On the other hand, a diet high in fruits and vegetables is linked to a lower risk of esophageal cancer. The exact reasons for this are not clear, but fruits and vegetables have a number of vitamins and minerals that may help prevent cancer.

Frequently drinking very hot liquids (temperatures of 149° F or 65° C – much hotter than a typical cup of coffee) may increase the risk for the squamous cell type of esophageal cancer. This might be the result of long-term damage to the cells lining the esophagus from the hot liquids.

Achalasia

In this condition, the muscle at the lower end of the esophagus (the lower esophageal sphincter) does not relax properly. Food and liquid that are swallowed have trouble passing into the stomach and tend to collect in the lower esophagus, which becomes stretched out (dilated) over time. The cells lining the esophagus in that area can become irritated from being exposed to foods for longer than normal amounts of time.

People with achalasia have a risk of esophageal cancer that is many times normal. On average, the cancers are found about 15 to 20 years after the achalasia began.

Tylosis

This is a rare, inherited disease that causes excess growth of the top layer of skin on the palms of the hands and soles of the feet. People with this condition also develop small growths (papillomas) in the esophagus and have a very high risk of getting squamous cell cancer of the esophagus.

People with tylosis need to be watched closely to try to find esophageal cancer early. Often this requires regular monitoring with an upper endoscopy.

Plummer-Vinson syndrome

People with this rare syndrome (also called Paterson-Kelly syndrome) have webs in the upper part of the esophagus, typically along with anemia (low red blood cell counts) due to low iron levels, tongue irritation (glossitis), brittle fingernails, and sometimes a large thyroid gland or spleen.

A web is a thin membrane extending out from the inner lining of the esophagus that causes an area of narrowing. Most esophageal webs do not cause any problems, but larger ones can cause food to get stuck in the esophagus, which can lead to problems swallowing and chronic irritation in that area from the trapped food.

About 1 in 10 people with this syndrome eventually develop squamous cell cancer of the esophagus or cancer in the lower part of the throat (hypopharynx).

Workplace exposures

Exposure to chemical fumes in certain workplaces may lead to an increased risk of esophageal cancer. For example, exposure to some of the solvents used for dry cleaning might lead to a greater risk of esophageal cancer. Some studies have found that dry cleaning workers may have a higher rate of esophageal cancer, but not all studies have found this link.

Injury to the esophagus

Lye is a chemical found in strong industrial and household cleaners such as drain cleaners. Lye is a corrosive agent that can burn and destroy cells. Accidentally drinking from a lye-based cleaner bottle can cause a severe chemical burn in the esophagus. As the injury heals, the scar tissue can cause an area of the esophagus to become very narrow (called a stricture). People with these strictures have an increased risk of squamous cell esophageal cancer, which often occurs many years (even decades) later.

History of certain other cancers

People who have had certain other cancers, such as lung cancer, mouth cancer, and throat cancer have a high risk of getting squamous cell carcinoma of the esophagus as well. This may be because these cancers can also be caused by smoking.

Human papilloma virus (HPV) infection

HPV is a group of more than 100 related viruses. They are called papilloma viruses because some of them cause a type of growth called a papilloma (or wart). Infection with certain types of HPV is linked to a number of cancers, including throat cancer, anal cancer, and cervical cancer.

Signs of HPV infection have been found in up to one-third of esophagus cancers from patients in parts of Asia and South Africa. But signs of HPV infection have not been found in esophagus cancers from patients in the other areas, including the US.

Radiotherapy

Radiotherapy for other cancers slightly increases your risk of esophageal cancer, including

• breast cancer
• lung cancer
• oropharynx cancer
• larynx cancer
• Hodgkin lymphoma

Your risk of getting esophageal cancer is still small. You would be at a higher risk from your existing cancer if you didn’t have the radiotherapy your doctor recommends.

Esophageal Cancer Prevention

Not all esophageal cancers can be prevented, but the risk of developing this disease can be greatly reduced by avoiding certain risk factors.

Avoiding tobacco and alcohol

In the United States, the most important lifestyle risk factors for cancer of the esophagus are the use of tobacco and alcohol. Each of these factors alone increases the risk of esophageal cancer many times, and the risk is even greater if they are combined. Avoiding tobacco and alcohol is one of the best ways of limiting your risk of esophageal cancer. If you or someone you know would like to quit tobacco, call us at 1-800-227-2345 or see Stay Away from Tobacco.

Watching your diet and body weight

Eating a healthy diet and staying at a healthy weight are also important. A diet rich in fruits and vegetables may help protect against esophageal cancer. Obesity has been linked with esophageal cancer, particularly the adenocarcinoma type, so staying at a healthy weight may also help limit the risk of this disease.

Getting treated for gastroesophageal reflux or Barrett’s esophagus

Treating people with reflux may help prevent Barrett’s esophagus and esophageal cancer. Often, reflux is treated using drugs called proton pump inhibitors (PPIs), such as omeprazole (Prilosec®), lansoprazole (Prevacid®), or esomeprazole (Nexium®). Surgery might also be an option for treating reflux if the reflux is not controlled with medical therapy alone.

People at a higher risk for esophageal cancer, such as those with Barrett’s esophagus, are often watched closely by their doctors to look for signs that the cells lining the esophagus have become more abnormal. If dysplasia (a pre-cancerous condition) is found, the doctor may recommend treatments to keep it from developing into esophageal cancer.

For those who have Barrett’s esophagus, daily treatment with a proton pump inhibitor might lower the risk of developing cell changes (dysplasia) that can turn into cancer. If you have chronic heartburn (or reflux), tell your doctor. Treatment can often improve symptoms and might prevent future problems.

Some studies have found that the risk of cancer of the esophagus is lower in people with Barrett’s esophagus who take aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. However, taking these drugs every day can lead to problems, such as kidney damage and bleeding in the stomach. For this reason, most doctors don’t advise that people take NSAIDs to try to prevent cancer. If you are thinking of taking an NSAID regularly, discuss the potential benefits and risks with your doctor first.

Some studies have also found a lower risk of esophageal cancer in people with Barrett’s esophagus who take drugs called statins, which are used to treat high cholesterol. Examples include atorvastatin (Lipitor®) and rosuvastatin (Crestor®). While taking one of these drugs might help some patients lower esophageal cancer risk, doctors don’t advise taking them just to prevent cancer because they can have serious side effects.

Esophageal cancer signs and symptoms

Early esophageal cancer typically causes no signs or symptoms.

Cancers of the esophagus are usually found because of the symptoms they cause. Diagnosis in people without symptoms is rare and usually accidental (because of tests done for other medical problems). Unfortunately, most esophageal cancers do not cause symptoms until they have reached an advanced stage, when they are harder to treat.

Signs and symptoms of esophageal cancer include:

• Difficulty swallowing (dysphagia)
• Weight loss without trying
• Chest pain, pressure or burning
• Worsening indigestion or heartburn
• Coughing or hoarseness

Trouble swallowing (dysphagia)

The most common symptom of esophageal cancer is a problem swallowing, with a feeling like the food is stuck in the throat or chest, or even choking on food. The medical term for trouble swallowing is dysphagia. This is often mild when it starts, and then gets worse over time as the opening inside the esophagus gets smaller.

When swallowing becomes harder, people often change their diet and eating habits without realizing it. They take smaller bites and chew their food more carefully and slowly. As the cancer grows larger, the problem can get worse. People then might start eating softer foods that can pass through the esophagus more easily. They might avoid bread and meat, since these foods typically get stuck. The swallowing problem may even get bad enough that some people stop eating solid food completely and switch to a liquid diet. If the cancer keeps growing, at some point even liquids might be hard to swallow.

To help pass food through the esophagus, the body makes more saliva. This causes some people to complain of bringing up lots of thick mucus or saliva.

A harmless narrowing of the esophagus called a stricture can also make it difficult for you to swallow. It is important to get this symptom checked by your doctor.

Food coming back up

You may regurgitate food – this is when food comes back up soon after you swallow it. It usually starts with food like meat and bread. You may start to bring up soft foods such as mashed potato, drinks and saliva if you don’t have treatment.

Chest pain

Sometimes, people have pain or discomfort in the middle part of their chest. Some people get a feeling of pressure or burning in the chest. These symptoms are more often caused by problems other than cancer, such as heartburn, so they are rarely seen as a signal that a person might have cancer.

You can get indigestion when acid from the stomach goes back up (refluxes) into the esophagus or if the stomach is inflamed or irritated.

The valve between the stomach and esophagus normally stops this from happening. The valve is called the cardiac sphincter. A tumor that develops here can stop the valve working, causing indigestion.

Remember that indigestion is common and it’s not usually caused by cancer. It can be very painful, even when there’s nothing seriously wrong.

See your doctor if you’ve had heartburn most days for 3 weeks or more, even if you’re taking medicine and it seems to help. Heartburn is burning chest pain or discomfort that happens after eating.

Swallowing may become painful if the cancer is large enough to limit the passage of food through the esophagus. Pain may be felt a few seconds after swallowing, as food or liquid reaches the tumor and has trouble getting past it.

Weight loss

About half of people with esophageal cancer lose weight (without trying to). This happens because their swallowing problems keep them from eating enough to maintain their weight. Other factors include a decreased appetite and an increase in metabolism from the cancer.

Other symptoms

Other possible symptoms of cancer of the esophagus can include:

• Hoarseness
• Chronic cough
• Vomiting
• Hiccups
• Bone pain
• Bleeding into the esophagus. This blood then passes through the digestive tract, which may turn the stool black. Over time, this blood loss can lead to anemia (low red blood cell levels), which can make a person feel tired.

Having one or more of the symptoms above does not mean you have esophageal cancer. In fact, many of these symptoms are more likely to be caused by other conditions. Still, if you have any of these symptoms, especially trouble swallowing, it’s important to have them checked by a doctor so that the cause can be found and treated, if needed.

Can Esophageal Cancer Be Found Early?

Screening is the process of looking for cancer or pre-cancer in people who have no symptoms of the disease. In the United States, screening the general public for esophageal cancer is not recommended by any professional organization at this time. This is because no screening test has been shown to lower the risk of dying from esophageal cancer in people who are at average risk.

However, people who have a high risk of esophageal cancer, such as those with Barrett’s esophagus, are often followed closely to look for early cancers and pre-cancers.

Testing people at high risk

Many experts recommend that people with a high risk of esophageal cancer, such as those with Barrett’s esophagus, have upper endoscopy regularly. For this test, the doctor looks at the inside of the esophagus through a flexible lighted tube called an endoscope. The doctor may remove small samples of tissue (biopsies) from the area with Barrett’s so that they can be checked for dysplasia (pre-cancer cells) or cancer cells.

Doctors aren’t certain how often the test should be repeated, but most recommend testing more often if areas of dysplasia are found. This testing is repeated even more often if there is high-grade dysplasia (the cells appear very abnormal).

If the area of Barrett’s is large and/or there is high-grade dysplasia, treatment of the abnormal area might be advised because of the high risk that an adenocarcinoma is either already present (but was not found) or will develop within a few years. Treatment options for high-grade dysplasia might include surgery to remove part of the esophagus with the abnormal area, endoscopic mucosal resection, photodynamic therapy (PDT), or radiofrequency ablation. The outlook for these patients is relatively good after treatment.

Careful monitoring and treatment (if needed) may help prevent some esophageal cancers from developing. It may also detect some cancers early, when they are more likely to be treated successfully.

Esophageal cancer complications

As esophageal cancer advances, it can cause complications, such as:

• Obstruction of the esophagus. Cancer may make it difficult or impossible for food and liquid to pass through your esophagus.
• Pain. Advanced esophageal cancer can cause pain.
• Bleeding in the esophagus. Esophageal cancer can cause bleeding. Though bleeding is usually gradual, it can be sudden and severe at times.

Esophageal cancer diagnosis

Esophagus cancers are usually found because of signs or symptoms a person is having. If esophagus cancer is suspected, exams and tests will be needed to confirm the diagnosis. If cancer is found, further tests will be done to help determine the extent (stage) of the cancer.

Medical history and physical exam

If you have symptoms that might be caused by esophageal cancer, the doctor will ask about your medical history to check for possible risk factors and to learn more about your symptoms.

Your doctor will also examine you to look for possible signs of esophageal cancer and other health problems. He or she will probably pay special attention to your neck and chest areas.

If the results of the exam are abnormal, your doctor will probably order tests to help find the problem. You may also be referred to a gastroenterologist (a doctor specializing in digestive system diseases) for further tests and treatment.

Imaging tests to look for esophagus cancer

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. Imaging tests might be done for many reasons, such as:

• To help find a suspicious area that might be cancer
• To learn if and how far cancer has spread
• To help determine if the treatment is working
• To look for possible signs of cancer coming back after treatment

Barium swallow

In this test, a thick, chalky liquid called barium is swallowed to coat the walls of the esophagus. When x-rays are then taken, the barium clearly outlines the esophagus. This test can be done by itself, or as a part of a series of x-rays that includes the stomach and part of the intestine, called an upper gastrointestinal (GI) series. A barium swallow test can show any abnormal areas in the normally smooth surface of the inner lining of the esophagus, but it can’t be used to determine how far a cancer may have spread outside of the esophagus.

This is sometimes the first test done to see what is causing a problem with swallowing. Even small, early cancers can often be seen using this test. Early cancers can look like small round bumps or flat, raised areas (called plaques), while advanced cancers look like large irregular areas and can cause narrowing of the inside of the esophagus.

This test can also be used to diagnose one of the more serious complications of esophageal cancer called a tracheo-esophageal fistula. This occurs when the tumor destroys the tissue between the esophagus and the trachea (windpipe) and creates a hole connecting them. Anything that is swallowed can then pass from the esophagus into the windpipe and lungs. This can lead to frequent coughing, gagging, or even pneumonia. This problem can be helped with surgery or an endoscopy procedure.

Computed tomography (CT or CAT) scan

A CT scan uses x-rays to produce detailed cross-sectional images of your body. This test can help tell if esophageal cancer has spread to nearby organs and lymph nodes (bean-sized collections of immune cells to which cancers often spread first) or to distant parts of the body.

Before the test, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the esophagus and intestines. If you are having any trouble swallowing, you need to tell your doctor before the scan.

Magnetic resonance imaging (MRI) scan

Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. A contrast material called gadolinium may be injected into a vein before the scan to see details better. MRI can be used to look at abnormal areas in the brain and spinal cord that might be due to cancer spread.

Positron emission tomography (PET) scan

PET scans usually use a form of radioactive sugar (known as fluorodeoxyglucose or FDG) that is injected into the blood. Normal cells use different amounts of the sugar, depending on how fast they are growing. Cancer cells, which grow quickly, are more likely to absorb larger amounts of the radioactive sugar than normal cells. These areas of radioactivity can be seen on a PET scan using a special camera.

The picture from a PET scan is not as detailed as a CT or MRI scan, but it provides helpful information about whether abnormal areas seen on these other tests are likely to be cancer or not.

If you have already been diagnosed with cancer, your doctor may use this test to see if the cancer has spread to lymph nodes or other parts of the body. A PET scan can also be useful if your doctor thinks the cancer may have spread but doesn’t know where.

PET/CT scan: Some machines can do both a PET and CT scan at the same time. This lets the doctor compare areas of higher radioactivity on the PET scan with the more detailed picture of that area on the CT scan.

Endoscopy

An endoscope is a flexible, narrow tube with a tiny video camera and light on the end that is used to look inside the body. Tests that use endoscopes can help diagnose esophageal cancer or determine the extent of its spread.

Upper endoscopy

This is an important test for diagnosing esophageal cancer. During an upper endoscopy, you are sedated (made sleepy) and then the doctor passes an endoscope down yourthroat and into the esophagus and stomach. The camera is connected to a monitor, which lets the doctor see any abnormal areas in the wall of the esophagus clearly.

The doctor can use special instruments through the scope to remove (biopsy) samples from any abnormal areas. These samples are sent to the lab to see if they contain cancer.

If the esophageal cancer is blocking the opening (called the lumen) of the esophagus, certain instruments can be used to help enlarge the opening to help food and liquid pass.

Upper endoscopy can give the doctor important information about the size and spread of the tumor, which can be used to help determine if the tumor can be removed with surgery.

Endoscopic ultrasound

This test is usually done at the same time as the upper endoscopy. For an endoscopic ultrasound, a probe that gives off sound waves is at the end of an endoscope. This allows the probe to get very close to tumors in the esophagus. This test is very useful in determining the size of an esophageal cancer and how far it has grown into nearby areas. It can also help show if nearby lymph nodes might be affected by the cancer. If enlarged lymph nodes are seen on the ultrasound, the doctor can pass a thin, hollow needle through the endoscope to get biopsy samples of them. This helps the doctor decide if the tumor can be removed with surgery.

Bronchoscopy

This exam may be done for cancer in the upper part of the esophagus to see if it has spread to the windpipe (trachea) or the tubes leading from the windpipe into the lungs (bronchi).

Thoracoscopy and laparoscopy

These exams let the doctor see lymph nodes and other organs near the esophagus inside the chest (by thoracoscopy) or the abdomen (by laparoscopy) through a hollow lighted tube.

These procedures are done in an operating room while you are under general anesthesia (in a deep sleep). A small incision (cut) is made in the side of the chest wall (for thoracoscopy) or the abdomen (for laparoscopy). Sometimes more than one cut is made. The doctor then inserts a thin, lighted tube with a small video camera on the end through the incision to view the space around the esophagus. The surgeon can pass thin tools into the space to remove lymph nodes and biopsy samples to see if the cancer has spread. This information is often important in deciding whether a person is likely to benefit from surgery.

Lab tests of biopsy samples

Usually if a suspected esophageal cancer is found on endoscopy or an imaging test, it is biopsied. In a biopsy, the doctor removes a small piece of tissue with a special instrument passed through the scope.

HER2 testing: If esophageal cancer is found but is too advanced for surgery, your biopsy samples may be tested for the HER2 gene or protein. Some people with esophageal cancer have too much of the HER2 protein on the surface of their cancer cells, which helps the cells grow. A drug that targets the HER2 protein called trastuzumab (Herceptin®) may help treat these cancers when used along with chemotherapy. Only cancers that have too much of the HER2 gene or protein are likely to be affected by this drug, which is why doctors may test tumor samples for it.

Blood tests

Your doctor might order certain blood tests to help determine if you have esophageal cancer.

Complete blood count (CBC): This test measures the different types of cells in your blood. It can show if you have anemia (too few red blood cells). Some people with esophageal cancer become anemic because the tumor has been bleeding.

Liver enzymes: You may also have a blood test to check your liver function, because esophageal cancer can spread to the liver.

Esophageal cancer staging

After someone is diagnosed with esophageal cancer, doctors will try to figure out if it has spread, and if so, how far. This process is called staging. The stage of a cancer describes how much cancer is in the body. It helps determine how serious the cancer is and how best to treat it. Doctors also use a cancer’s stage when talking about survival statistics.

The earliest stage esophageal cancers are called stage 0 (high grade dysplasia). It then ranges from stage I (1) through IV (4). As a rule, the lower the number, the less the cancer has spread. A higher number, such as stage IV, means cancer has spread more. And within a stage, an earlier letter means a lower stage. Although each person’s cancer experience is unique, cancers with similar stages tend to have a similar outlook and are often treated in much the same way.

Most esophageal cancers start in the innermost lining of the esophagus (the epithelium) and then grow into deeper layers over time.

How is the esophageal cancer stage determined?

The staging system most often used for esophageal cancer is the American Joint Committee on Cancer (AJCC) TNM system, which is based on 3 key pieces of information:

• The extent (size) of the tumor (T): How far has the cancer grown into the wall of the esophagus? Has the cancer reached nearby structures or organs?
• The spread to nearby lymph nodes (N): Has the cancer spread to nearby lymph nodes?
• The spread (metastasis) to distant sites (M): Has the cancer spread to distant lymph nodes or distant organs such as the lungs or liver?

Numbers or letters after T, N, and M provide more details about each of these factors. Higher numbers mean the cancer is more advanced. Once a person’s T, N, and M categories have been determined, this information is combined in a process called stage grouping to assign an overall stage.

Staging systems for esophageal cancer

Since esophageal cancer can be treated in different ways, different staging systems have been created for each situation:

• Pathological stage (also called the surgical stage): If surgery is done first, the pathological stage is determined by examining tissue removed during an operation. This is the most common system used.
• Clinical stage: If surgery might not be possible or will be done after other treatment is given, then the clinical stage is determined based on the results of a physical exam, biopsy, and imaging tests. The clinical stage will be used to help plan treatment, but it might not predict outlook as accurately as the pathologic stage. This is because sometimes the cancer has spread further than the clinical stage estimates.
• Postneoadjuvant stage: If surgery is done after other treatments such as chemotherpay or radiation have been given (this is called neoadjuvant therapy), then a separate postneoadjuvant stage will be determined after surgery.

Since most cancers are staged with the pathological stage, we have included that staging system in the tables below. If your cancer has been clinically staged or if you have had neoadjuvant therapy, it is best to talk to your doctor about your specific stage for those situations.

Grade

Another factor that can affect your treatment and your outlook is the grade of your cancer. The grade describes how closely the cancer looks like normal tissue when seen under a microscope.

The scale used for grading esophagus cancers is from 1 to 3.

• GX: The grade cannot be assessed.(The grade is unknown).
• Grade 1 (G1: well differentiated) means the cancer cells look more like normal esophagus tissue.
• Grade 3 (G3: poorly differentiated, undifferentiated) means the cancer cells look very abnormal.
• Grades 2 (G2: moderately differentiated) falls somewhere in between G1 and G3.

The grade is often simplified as either low grade (G1) or high grade (G3).

Low-grade cancers tend to grow and spread more slowly than high-grade cancers. Most of the time, the outlook is better for low-grade cancers than it is for high-grade cancers of the same stage.

Location

Some stages of early squamous cell carcinoma also take into account where the tumor is in the esophagus. The location is assigned as either upper, middle, or lower based on where the middle of the tumor is.

Esophageal cancer stage descriptions

The tables below are simplified versions of the TNM system, based on the most recent American Joint Committee on Cancer (AJCC) systems effective January 2018. They include staging systems for squamous cell carcinoma and adenocarcinoma. It’s important to know that esophageal cancer staging can be complex. If you have any questions about the stage of your cancer or what it means, please ask your doctor to explain it to you in a way you understand.

Table 1. Squamous Cell Carcinoma Stages

Table 2. Adenocarcinoma stages

The location of the cancer in the esophagus does not affect the stage of adenocarcinomas.

Resectable versus unresectable cancer

The American Joint Committee on Cancer (AJCC) staging system provides a detailed summary of how far an esophagus cancer has spread. But for treatment purposes, doctors are often more concerned about whether the cancer can be removed completely with surgery (resected). If, based on where the cancer is located and how far it has spread, it could be removed completely by surgery, it is considered potentially resectable. If the cancer has spread too far to be removed completely, it is considered unresectable.

As a general rule, all stage 0, I, and II esophageal cancers are potentially resectable. Most stage III cancers are potentially resectable also, even when they have spread to nearby lymph nodes, as long as the cancer has not grown into the trachea (windpipe), the aorta (the large blood vessel coming from the heart), the spine, or other nearby important structures. Unfortunately, many people whose cancer is potentially resectable might not be able to have surgery to remove their cancers because they aren’t healthy enough.

Cancers that have grown into nearby structures or that have spread to distant lymph nodes or to other organs are considered unresectable, so treatments other than surgery are usually the best option.

Esophageal cancer survival rate

Statistics on the outlook for a certain type and stage of cancer are often given as 5-year survival rates, but many people live longer than 5 years. The 5-year survival rate is the percentage of people who live at least 5 years after being diagnosed with cancer.

But remember, the 5-year relative survival rates are estimates – your outlook can vary based on many factors specific to you.

Cancer survival rates don’t tell the whole story

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they can’t predict what will happen in any particular person’s case. There are a number of limitations to remember:

• The numbers below are among the most current available. But to get 5-year survival rates, doctors must look at people who were treated at least 5 years ago.
• As treatments are improving over time, people who are now being diagnosed with esophageal cancer may have a better outlook than these statistics show.
• These statistics are based on the stage of the cancer when it was first diagnosed. They do not apply to cancers that later come back or spread, for example.
• The outlook for people with esophageal cancer varies by the stage (extent) of the cancer – in general, the survival rates are better for people with earlier stage cancers. But many other factors can affect a person’s outlook, such as age and overall health, and how well the cancer responds to treatment. The outlook for each person is specific to his or her circumstances.

Your doctor can tell you how these numbers may apply to you, as he or she is familiar with your situation.

The numbers below come from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database, looking at people diagnosed with esophageal cancer between 2007 and 2013. The SEER database doesn’t divide survival rates by AJCC TNM stage. Instead, it divides cancers into 3 larger, summary stages:

Localized means that the cancer is only growing in the esophagus. It includes AJCC stage I and some stage II tumors (such as those that are T1, T2, or T3, N0, M0). Stage 0 cancers are not included in these statistics.
Regional means that the cancer has spread to nearby lymph nodes or tissues. This includes T4 tumors and cancers with lymph node spread (N1, N2, or N3).
Distant means that the cancer has spread to organs or lymph nodes away from the tumor, and includes all M1 (stage IV) cancers.

Table 3. Esophageal cancer life expectancy

These survival rates for esophageal cancer do not separate squamous cell carcinomas from adenocarcinomas, although people with adenocarcinomas are generally thought to have a slightly better prognosis (outlook) overall.

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they can’t predict what will happen with any specific person. Knowing the type and the stage of a person’s cancer is important in estimating their outlook. But many other factors are also important, such as the treatment received, how well the cancer responds to treatment, and a person’s overall health. Even when taking these other factors into account, survival rates are at best rough estimates. Your doctor can tell you how well these numbers may apply to you, as he or she knows your situation best.

Esophageal cancer treatment

What treatments you receive for esophageal cancer are based on the type of cells involved in your cancer, your cancer’s stage, your overall health and your preferences for treatment.

If you’ve been diagnosed with esophageal cancer, your cancer care team will discuss your treatment options with you. It’s important that you think carefully about each of your choices. You will want to weigh the benefits of each treatment option against the possible risks and side effects.

Which treatments are used for esophageal cancer?

There are several ways to treat esophageal cancer, depending on its type and stage.

Local treatments: Some treatments are called local therapies, meaning they treat the tumor in a specific location, without affecting the rest of the body. Types of local therapy used for esophageal cancer include:

• Surgery
• Radiation therapy
• Endoscopic treatments

These treatments are more likely to be useful for earlier stage (less advanced) cancers, although they might also be used in some other situations.

Systemic treatments: Esophageal cancer can also be treated using drugs, which can be given by mouth or directly into the bloodstream. These are called systemic therapies because they travel through your whole system, allowing them to reach cancer cells almost anywhere in the body. Depending on the type of esophageal cancer, several different types of drugs might be used, including:

• Chemotherapy
• Targeted therapy
• Immunotherapy

Depending on the stage of the cancer and other factors, different types of treatment may be combined at the same time or used after one another.

Esophageal cancer surgery

For some earlier stage cancers, surgery can be used to try to remove the cancer and some of the normal surrounding tissue. In some cases, it might be combined with other treatments, such as chemotherapy and/or radiation therapy.

Esophagectomy

Surgery to remove some or most of the esophagus is called an esophagectomy. Often a small part of the stomach is removed as well. The upper part of the esophagus is then connected to the remaining part of the stomach. Part of the stomach is pulled up into the chest or neck to become the new esophagus. How much of the esophagus is removed depends upon the stage of the tumor and where it’s located:

• If the cancer is in the lower part of the esophagus (near the stomach) or at the place where the esophagus and stomach meet (the gastroesophageal or GE junction), the surgeon will remove part of the stomach, the part of the esophagus containing the cancer, and about 3 to 4 inches (about 7.6 to 10 cm) of normal esophagus above this. Then the stomach is connected to what is left of the esophagus either high in the chest or in the neck.
• If the tumor is in the upper or middle part of the esophagus, most of the esophagus will need to be removed to be sure to get enough tissue above the cancer. The stomach will then be brought up and connected to the esophagus in the neck. If for some reason the stomach can’t be pulled up to attach it to the remaining part of the esophagus, the surgeon may use a piece of the intestine to bridge the gap between the two. When a piece of intestine is used, it must be moved without damaging its blood vessels. If the vessels are damaged, not enough blood will get to that piece of intestine, and the tissue will die.

Esophagectomy techniques

Open esophagectomy: In the standard, open technique, the surgeon operates through one or more large incisions (cuts) in the neck, chest, or abdomen (belly). Many different approaches can be used to remove part of the esophagus.

• For a transthoracic esophagectomy, the esophagus is removed with the main incisions in the abdomen and the chest.
• If the main incisions are in the abdomen and neck, it is called a transhiatal esophagectomy.
• Some procedures are done through incisions in the neck, chest, and abdomen.

You and your surgeon should discuss in detail the operation planned for you and what you can expect.

Minimally invasive esophagectomy: For some early (small) cancers, the esophagus can be removed through several small incisions instead of large incisions. The surgeon puts a scope (like a tiny telescope) through one of the incisions to see everything during the operation. Then the surgical instruments go in through other small incisions. To do this type of procedure well, the surgeon needs to be highly skilled and have a great deal of experience removing the esophagus this way. Because it uses smaller incisions, minimally invasive esophagectomy may allow the patient to leave the hospital sooner and recover faster.

No matter which approach is used, esophagectomy is not a simple operation, and it may require a long hospital stay. It is very important to have it done at a center that has a lot of experience treating these cancers and performing these procedures.

If the cancer has not yet spread far beyond the esophagus, removing the esophagus (and nearby lymph nodes) may cure the cancer. Unfortunately, most esophageal cancers are not found early enough for doctors to cure them with surgery.

Lymph node removal

For either type of esophagectomy, nearby lymph nodes are also removed during the operation as well. These are then checked in the lab to see if they contain cancer cells. If the cancer has spread to lymph nodes, the outlook is not as good, and the doctor may recommend other treatments (like chemotherapy and/or radiation) after surgery.

Possible risks of esophagectomy

Like most serious operations, surgery of the esophagus has some risks.

• Short-term risks include reactions to anesthesia, excess bleeding, blood clots in the lungs or elsewhere, and infections. Most people will have at least some pain after the operation, which can usually be helped with pain medicines.
• Lung complications are common. Pneumonia may develop, leading to a longer hospital stay, and sometimes even death.
• Some people might have voice changes after the surgery.
• There may be a leak at the place where the stomach (or intestine) is connected to the esophagus, which might require another operation to fix. This is not as common as it used to be because of improvements in surgical techniques.
• Strictures (narrowing) can form where the esophagus is surgically connected to the stomach, which can cause problems swallowing for some patients. To relieve this symptom, these strictures can be expanded during an upper endoscopy procedure.
• After surgery, the stomach may empty too slowly because the nerves that control its contractions can be affected by surgery. This can sometimes lead to frequent nausea and vomiting.
• After surgery, bile and stomach contents can back up into the esophagus because the ring-shaped muscle that normally controls this (the lower esophageal sphincter) is often removed or changed by the surgery. This can cause symptoms such as heartburn. Sometimes antacids or motility drugs can help relieve these symptoms.

Some complications from this surgery can be life threatening. The risk of dying from this operation is related to the doctor’s experience with these procedures. In general, the best outcomes are achieved with surgeons and hospitals that have the most experience. This is why patients should ask the surgeon about his or her experience: how often they operate on the esophagus, how many times they have done this procedure, and what percentage of their patients have died after this surgery. The hospital where the surgery is done is also important, and any hospital that you consider should be willing to show you their survival statistics.

Surgery for palliative care

Sometimes minor types of surgery are used to help prevent or relieve problems caused by the cancer, instead of trying to cure it. For example, minor surgery can be used to place a feeding tube directly into the stomach or small intestine in people who need help getting enough nutrition.

Endoscopic Treatments for Esophageal Cancer

Several types of treatment for esophageal cancer can be done by passing an endoscope (a long, flexible tube) down the throat and into the esophagus. Some of these treatments may be used to try to cure very early stage cancers, or even to prevent them from developing by treating Barrett’s esophagus or dysplasia. Other treatments are used mainly to help relieve symptoms from more advanced esophageal cancers that can’t be removed.

Endoscopic mucosal resection

Endoscopic mucosal resection (EMR) can be used for dysplasia (pre-cancer) and some small, very early-stage cancers of the esophagus.

In this technique, a piece of the inner lining of the esophagus is removed with instruments passed down the endoscope. After the abnormal tissue is removed, patients take drugs called proton pump inhibitors to suppress acid production in the stomach. This can help keep the disease from returning.

The most common side effect of endoscopic mucosal resection is bleeding in the esophagus, which is usually not serious. Less common but more serious side effects can include esophageal strictures (areas of narrowing) that might need to be treated by with dilation, and puncture (perforation) of the wall of the esophagus.

Photodynamic therapy

Photodynamic therapy (PDT) can be used to treat Barrett’s esophagus, esophageal pre-cancers (dysplasia), and some very early stage esophageal cancers. It is also often used to treat large cancers that are blocking the esophagus. In this situation, photodynamic therapy is not meant to destroy all the cancer, but to kill enough of the cancer to improve a person’s ability to swallow.

For this technique, a light-activated drug called porfimer sodium (Photofrin®) is injected into a vein. Over the next couple of days, the drug is more likely to collect in cancer cells than in normal cells. A special type of laser light is then focused on the cancer through an endoscope. This light changes the drug into a new chemical that can kill the cancer cells. The dead cells may then be removed a few days later during an upper endoscopy. This process can be repeated if needed.

The advantage of photodynamic therapy is that it can kill cancer cells with very little harm to normal cells. But because the chemical must be activated by light, it can only kill cancer cells near the inner surface of the esophagus – those that can be reached by the light. This light cannot reach cancers that have spread deeper into the esophagus or to other organs.

Photodynamic therapy can cause swelling in the esophagus for a few days, which may lead to some problems swallowing. Strictures (areas of extreme narrowing) can also happen. These often need to be treated by with dilation. Other possible side effects include bleeding or holes in the esophagus.

Some of this drug also collects in normal cells in the body, such as skin and eye cells. This can make you very sensitive to sunlight or strong indoor lights. Too much exposure can cause serious skin reactions, which is why doctors recommend staying out of any strong light for 4 to 6 weeks after the injection.

This treatment can cure some very early esophageal cancers that have not spread to deeper tissues. But this procedure destroys the tissue, so it can be hard to be certain that the cancer hasn’t spread into deeper layers of the esophagus. Since the light used in photodynamic therapy can only reach those cancer cells near the surface of the esophagus, cells of deeper cancers could be left behind, and grow into a new tumor. People getting this treatment need to have follow-up endoscopies to make sure the cancer hasn’t grown back. They also need to stay on a drug called a proton pump inhibitor to stop stomach acid production.

Radiofrequency ablation (RFA)

This procedure can be used to treat dysplasia in areas of Barrett’s esophagus. It may lower the chance of cancer developing in that area.

A balloon containing many small electrodes is passed into an area of Barrett’s esophagus through an endoscope. The balloon is then inflated so that the electrodes are in contact with the inner lining of the esophagus. Then an electrical current is passed through it, which kills the cells in the lining by heating them.

Over time, normal cells will grow in to replace the Barrett’s cells. People getting this treatment need to stay on drugs to block stomach acid production after the procedure. Endoscopy (with biopsies) is then done periodically to watch for any further changes in the lining of the esophagus. Rarely, RFA can cause strictures (narrowing) or bleeding in the esophagus.

Treatments to help keep the esophagus open

Laser ablation

This technique can be used to help open the esophagus when it is blocked by an advanced cancer. This can help improve problems swallowing.

A laser beam is aimed at the cancer through the tip of an endoscope to destroy the cancerous tissue. The laser is called a neodymium: yttrium-aluminum-garnet (Nd:YAG) laser. Laser endoscopy can be helpful, but the cancer often grows back, so the procedure may need to be repeated every month or two.

Argon plasma coagulation

This technique is like laser ablation, but it uses argon gas and a high-voltage spark delivered through the tip of an endoscope. The spark causes the gas to reach very high temperatures, which can then be aimed at the tumor. This approach is used to help unblock the esophagus for people who have trouble swallowing.

Electrocoagulation (electrofulguration)

For this treatment, a probe is passed down into the esophagus through an endoscope to burn the tumor off with electric current. In some cases, this treatment can help relieve esophageal blockage.

Esophageal stent

A stent is a device that, once in place, self-expands (opens up) to become a tube that helps hold the esophagus open. Stents are made of mesh material. Most often stents are made of metal, but they can also be made of plastic. Using endoscopy, a stent can be placed into the esophagus across the length of the tumor.

How well the stent works depends on the type that is used and where it is placed. Stents will relieve trouble swallowing for most people. They are often used after other endoscopic treatments to help keep the esophagus open.

Figure 5. Esophageal stent

Treatments for complications

Treatments for esophageal obstruction and difficulty swallowing (dysphagia) can include:

• Relieving esophageal obstruction. If your esophageal cancer has narrowed your esophagus, a surgeon may use an endoscope and special tools to place a metal tube (stent) to hold the esophagus open. Other options include surgery, radiation therapy, chemotherapy, laser therapy and photodynamic therapy.
• Providing nutrition. Your doctor may recommend a feeding tube if you’re having trouble swallowing or if you’re having esophagus surgery. A feeding tube allows nutrition to be delivered directly to your stomach or small intestine, giving your esophagus time to heal after cancer treatment.

Chemotherapy

Chemotherapy is drug treatment that uses chemicals to kill cancer cells. Chemotherapy drugs are typically used before (neoadjuvant) or after (adjuvant) surgery in people with esophageal cancer. Chemotherapy can also be combined with radiation therapy. In people with advanced cancer that has spread beyond the esophagus, chemotherapy may be used alone to help relieve signs and symptoms caused by the cancer.

The chemotherapy side effects that you experience depend on which chemotherapy drugs you receive.

Radiation therapy

Radiation therapy uses high-powered X-ray beams to kill cancer cells. Radiation typically will come from a machine outside your body that aims the beams at your cancer (external beam radiation). Or, less commonly, radiation can be placed inside your body near the cancer (brachytherapy).

Radiation therapy is most often combined with chemotherapy in people with esophageal cancer. It’s typically used before surgery, or occasionally after surgery. Radiation therapy is also used to relieve complications of advanced esophageal cancer, such as when a tumor grows large enough to stop food from passing to your stomach. Treatment can last from two to six weeks of daily radiation treatments.

Side effects of radiation to the esophagus include sunburn-like skin reactions, painful or difficult swallowing, and accidental damage to nearby organs, such as the lungs and heart.

Combined chemotherapy and radiation

Combining chemotherapy and radiation therapy may enhance the effectiveness of each treatment. Combined chemotherapy and radiation may be the only treatment you receive, or combined therapy can be used before surgery. But combining chemotherapy and radiation treatments increases the likelihood and severity of side effects.

Coping and support

Coping with the shock, fear and sadness that come with a cancer diagnosis can take time. You may feel overwhelmed just when you need to make crucial decisions. With time, each person finds a way of coping and coming to terms with the diagnosis.

Until you find what brings you the most comfort, consider trying to:

• Find out enough about esophageal cancer to make decisions about your care. Ask your doctor for the specifics about your cancer, such as its type and stage. And ask for recommended sources of information where you can learn more about your treatment options. The National Cancer Institute ¹⁾ and the American Cancer Society ²⁾ are good places to start.
• Stay connected to friends and family. Your friends and family can provide a crucial support network for you during your cancer treatment. As you begin telling people about your esophageal cancer diagnosis, you’ll likely get offers for help. Think ahead about things you may like help with, whether it’s having someone to talk to if you’re feeling low or getting help preparing meals.
• Find someone to talk to. You might have a close friend or family member who’s a good listener. Or talk to a counselor, medical social worker, or pastoral or religious counselor.

Consider joining a support group for people with cancer. You may find strength and encouragement in being with people who are facing the same challenges you are. Ask your doctor, nurse or social worker about groups in your area. Or try online message boards, such as those available through the American Cancer Society ³⁾.

Alternative medicine

Complementary and alternative therapies may help you cope with the side effects of cancer and cancer treatment. For instance, people with esophageal cancer may experience pain caused by cancer treatment or by a growing tumor. Your doctor can work to control your pain by treating the cause or with medications. Still, pain may persist, and complementary and alternative therapies may help you cope.

Options include:

• Acupuncture
• Guided imagery
• Massage
• Relaxation techniques

Ask your doctor whether these options are safe for you.