Esophageal Cancer: Everything You Need to Know

Medically Reviewed by Poonam Sachdev on July 02, 2024
Written by Kim Painter
10 min read

Esophageal cancer occurs when cancer cells develop in the esophagus, the long muscular tube that runs from your throat to your stomach. Food goes from the mouth to the stomach through the esophagus. The cancer starts in the inner layer of the esophagus and can spread throughout the other layers of the esophagus and to other parts of the body (metastasis).

Types of esophageal cancer

There are two main types of esophageal cancer:

Squamous cell carcinoma. Squamous cells line the inner esophagus, and cancer developing from squamous cells can occur along the entire esophagus. But it's most often found in the upper or middle parts.

Adenocarcinoma. This is the most common type of esophageal cancer and develops from gland cells. It develops when gland cells replace the squamous cells that normally line the esophagus. This typically occurs in the lower esophagus near the stomach and is believed to be largely related to acid exposure.

Early on, you could have esophageal cancer with no symptoms. As it advances, symptoms of esophageal cancer may include:

  • Difficulty or pain when you swallow, which is the most common symptom
  • Weight loss, often as a result of swallowing problems and lost appetite
  • Pain in the chest, behind the breastbone, often after swallowing
  • Chronic coughing
  • Indigestion or heartburn
  • Chronic blood loss, leading to low blood levels of iron (anemia) or dark stools

Unusual symptoms of esophageal cancer could include:

  • Swollen lymph nodes in the neck
  • Vomiting or coughing up blood
  • Hoarseness
  • Hiccups, caused by pressure on nerves

Some people are more likely than others to develop esophageal cancer. Factors that can increase your risk include: 

  • Smoking or using other tobacco products
  • Drinking alcohol, with the risk rising the more you drink
  • Obesity
  • Gastroesophageal reflux disease (GERD), a form of acid reflux, in which contents and acid from the stomach back up into the esophagus
  • Barrett's esophagus, a condition that affects the lower part of the esophagus and may be caused by GERD
  • Human papillomavirus (HPV) infection
  • Cancer of the head or neck
  • Exposure at work to certain chemicals, including dry cleaning solvents
  • Not eating enough fruits and vegetables
  • Regularly drinking very hot liquids

Men and others assigned male at birth who are over age 60 are most likely to develop esophageal cancer. White men are most likely to develop adenocarcinoma of the esophagus. In Asian, Black, and Hispanic men, squamous cell carcinoma of the esophagus is more common than adenocarcinoma.

How does acid reflux increase the risk for esophageal cancer?

When stomach acid rises out of your stomach and into your esophagus, you can get immediate symptoms such as heartburn and indigestion. That's because the acid irritates and inflames the tissues outside the stomach. When this happens occasionally, it's not a big problem. But when it happens frequently, at least twice a week for several weeks, you have the chronic form, called gastroesophageal reflux disease (GERD). And that increases your risk for esophageal cancer. However, it's worth noting that while 20% of U.S. adults have GERD, most don't get esophageal cancer.

When it does happen, it's usually a gradual process. Frequent acid exposure over a long time can damage the esophagus, causing pain and ulcers. In some cases, it can trigger cell changes that may be diagnosed as Barrett's esophagus, which happens in about 10%-15% of people with GERD. If you do develop Barrett's esophagus, your risk of developing esophageal cancer is about 0.5% each year and can be lowered by frequent monitoring and treatment of precancerous changes.

The symptoms of esophageal cancer can overlap with other more common conditions. But if you have any of the symptoms, you should check with your doctor. It's especially important to get answers if you realize that you've recently changed your eating habits to ease swallowing — such as by taking smaller bites, eating softer food, or completely avoiding solid food.

To diagnose or rule out esophageal cancer, your doctor will review your symptoms, ask about your medical history, and examine you. In addition, they may order certain blood tests and X-rays.

Tests for esophageal cancer may include:

Barium swallow X-ray. You get this X-ray after drinking a liquid that coats your esophagus. This makes the esophagus stand out on the X-ray image so that your doctor can identify certain problems.

Endoscopy. For this test, the doctor passes an endoscope — a thin, lighted tube — down your throat into your esophagus to examine it. Endoscopic ultrasound uses sound waves to provide more information about the extent of tumor involvement in nearby tissues.

Biopsy .During an endoscopy, the doctor can take cells or tissue from your esophagus. The cells are examined under a microscope to look for cancer.

Esophageal ulcer vs. cancer

Testing of your esophagus can turn up other conditions causing your symptoms, including esophageal ulcers, which are open sores on the lining of your esophagus. These are not cancer. They are often caused by gastroesophageal reflux disease. Treatments include medicines to reduce stomach acid. You might need antibiotics as well.

What is esophageal cancer staging?

If you do have esophageal cancer, the next step will be what doctors call staging — finding out how advanced the cancer is. That will affect which treatments they recommend for you.

To help with staging, you may get several additional tests to confirm the location and depth of the cancerous tissue, or tumor, and to see if it has spread to nearby lymph nodes or more distant places in your body. The health care team will also look at your tumor cells to see if they appear to be slow-growing or more aggressive.

The tests might include:

  • Imaging scans such as CT, PET, and MRI
  • Bronchoscopy, a test in which a lighted tube is inserted through your nose or mouth to look at your windpipe and bronchi (tubes leading into your lungs)
  • Thoracoscopy and laparoscopy, tests in which small incisions and thin lighted tubes are used to look into and take samples from your chest and abdomen
  • Lab tests of biopsy samples to look for certain gene changes and proteins that can affect how the cancer might respond to treatment
  • Blood tests to check for anemia and for clues such as changes in liver enzymes that might suggest the cancer has spread to the liver

The stages of esophageal cancer are given a number (I through IV); the higher the number, the more advanced the cancer. The stages are:

Stage 0. Abnormal cells (not yet cancer) are found only in the layer of cells that line the esophagus. This stage is often found when someone with Barrett's esophagus has a routine biopsy.

Stage I. Cancer cells are found only in the layer of cells that line the esophagus.

Stage II. The cancer has reached the muscle layer or the outer wall of the esophagus. In addition, the cancer may have spread to one or two nearby lymph nodes (small glands that are part of the immune system).

Stage III. The cancer has reached deeper into the inner muscle layer or the connective tissue wall. It may have spread beyond the esophagus into surrounding organs and/or has spread to more lymph nodes near the esophagus.

Stage IV. This is the most advanced stage. The cancer has spread to other organs in the body and/or to lymph nodes far from the esophagus.

Esophageal cancer grades

In addition to looking at how deeply and how far your cancer has spread, your doctors will give your cancer cells a grade, which describes how close to normal the cells look under a microscope. The scale goes from 1 to 3, with grade 1 cells looking the most normal and grade 3 cells looking the least normal.

In general, low-grade cancers tend to grow more slowly than higher-grade cancers at the same stage.

As with many cancers, esophageal cancer treatment has a greater chance of success if it is caught early. Unfortunately, by the time esophageal cancer is diagnosed, it's often in an advanced stage, meaning it's spread throughout the esophagus and beyond.

Treatment of esophageal cancer depends on many factors, including the stage of the cancer and your overall health. It may include:

  • Surgeryto remove all or part of theesophagus
  • Radiation therapy to target and kill cancer cells 
  • Chemotherapy, in which powerful drugs attack cancer cells throughout the body
  • Targeted therapy with newer drugs that target specific aspects of a cancer to curb cancer growth and spread
  • Immunotherapy to help the immune system attack cancer cells
  • Photodynamic therapy to target cancer cells with a special laser light
  • Electrocoagulation, which uses electric current to destroy cancer cells
  • Cryotherapy, which freezes cancer cells to help shrink a tumor.

A procedure called endoscopic mucosal resection may be done to treat precancers or very small early cancers by removing the inner lining of the esophagus. Radiofrequency ablation treatment using a device that targets cancer cells with radiofrequency energy is sometimes used for early cancers.

Treatment options for esophageal cancer differ by stage and also depend on your health, preferences, and other factors. Here are some typical options at each stage.

Stage 0. Options include surgery, photodynamic therapy, radiofrequency ablation, or endoscopic mucosal resection.

Stage I. Some early tumors may be treated with ablation alone, but most people who are healthy enough for surgery get an operation to remove the part of the esophagus with the cancer. They may get chemotherapy with radiation before the surgery, at the same time, or after it. In some cases, the cancer can be treated with chemotherapy and radiation alone.

Stages II and III. In people who are healthy enough, typical treatment includes chemotherapy and radiation, followed by surgery. But in some cases, surgery alone or chemotherapy and radiation alone may be offered.

Stage IV. Esophageal cancer at this stage is hard to get rid of, so surgery to try to cure it is rarely an option. Treatment will aim to control the cancer for as long as possible and minimize symptoms as much as possible. Chemotherapy, radiation, targeted therapy, and immunotherapy may be offered.

Life expectancy for esophageal cancer

According to the American Cancer Society, the percentages of people who live for at least 5 years after diagnosis with esophageal cancer (taking into account that some people with the cancer will have other causes of death) are:

  • 49% for cancer that hasn't spread past the esophagus
  • 28% for cancer that has spread to nearby lymph nodes or other tissues
  • 6% for cancer that has spread farther in the body

You may be able to lower your risk of esophageal cancer by:

  • Avoiding tobacco
  • Not drinking alcohol, or drinking less
  • Eating more fruits and vegetables
  • Maintaining a weight that's healthy for you
  • Seeking treatment for reflux and heartburn
  • Avoiding solvents in the workplace
  • Avoiding HPV infection, by getting vaccinated if your doctor recommends it
  • Following your doctor's advice for screening if you have Barrett's esophagus

Surgery and other treatments for esophageal cancer can come with side effects such as nausea, vomiting, and heartburn. You may still have problems swallowing after treatment and need to use strategies such as eating smaller meals or using liquid nutritional supplements. You might see a nutritionist to talk about the best solutions for you.

If you are feeling depressed, anxious, or worried during or after cancer treatment, that's not unusual. Many people reach out for help from counselors, support groups, friends, family members, and faith organizations.

You also should expect to see your cancer doctor for regularly scheduled follow-up visits. But you should let your doctor know if you develop new symptoms or old symptoms come back between regular visits.

One possible complication is called dumping syndrome. That's a condition that can happen after all or part of your esophagus is removed. The changes in your digestive system can make food and gastric juices from your stomach move into your small intestine too quickly. Symptoms can start within minutes of eating a meal, especially one high in sugar, or may come on later.

Your doctor may suggest diet changes to ease dumping syndrome. In addition to eating smaller meals, you might cut back on sweets and eat more protein and fiber. If diet changes aren't enough, you might need medication or more surgery.

Esophageal cancer often has no early symptoms. But if you are having trouble swallowing, which is the most common symptom, it's important to get it checked out as soon as possible. If you already know you have problems with your esophagus, such as Barrett's esophagus, it's important to get regular follow-ups. Treatment for esophageal cancer is most successful if it's caught early.

Is esophageal cancer rare?

In the U.S., esophageal cancer is fairly rare, making up just 1% of cancer cases. The lifetime risk for a man is about 1 in 127; for a woman, it's 1 in 434. But it's more common in other parts of the world, including Iran, northern China, India, and southern Africa. Worldwide, it's the eighth most common cancer and the sixth leading cause of cancer deaths. Higher use of tobacco and alcohol, diets low in fruits and vegetables, and other risk factors likely play in role in areas where rates are high.

Does esophageal cancer spread fast?

Tumors in your esophagus can grow quickly or slowly without causing symptoms because your esophagus, unlike many parts of your body, can stretch to accommodate a growing tumor. As a tumor grows through the inner to the outer part of the esophagus, the chances increase that it will spread elsewhere in the body. Once that happens, the cancer can spread quickly.

What is an esophagus spasm and does it increase the risk for esophageal cancer?

An esophagus spasm is a rare abnormal muscle contraction in the esophagus. It can cause chest pain, trouble swallowing, a feeling that something is stuck in your throat, and other symptoms. The symptoms tend to come and go and sometimes are triggered by having very hot or cold foods and drinks. While some of the symptoms are the same as those of esophageal cancer, there's no link between the spasms and cancer.