What is Oesophageal cancer?
The oesophagus is a muscular tube that carries food and drink from the mouth to the
stomach. Oesophageal cancer can occur anywhere along this tube.
Oesophageal cancer is a condition that arises when normal cells lining the
oesophagus (food pipe) accumulate abnormal changes in their genetic material
(DNA mutations) and are transformed into harmful cancer cells that grow
uncontrollably and live longer than usual, damaging the oesophageal wall. Over
time, these cancer cells can break away and spread to nearby lymph nodes and
distant organs, such as the liver, lungs, and bones, through a process known as
metastasis.
Oesophageal cancer affects both males and females, but it is more common among
males and usually diagnosed in older adults.
According to GLOBOCAN 2020, oesophageal cancer is the 8th most diagnosed
cancer and the 6th leading cause of cancer-related death, with approximately
604,000 new cases and 544,000 deaths in 2020.
The disease shows strong geographical variation: rates are very high in parts of Asia
(especially the “oesophageal cancer belt” from northern Iran through Central Asia to
northern China) and eastern/southern Africa, while lower in Western Europe and
North America.
In the United Kingdom, there are around 9,400 new oesophageal cancer cases
and about 7,900 deaths each year and it is one of the cancers with lower long-term survival compared with many
others.
Why Do People Develop Oesophageal Cancer?
Oesophageal cancer develops from a combination of lifestyle-related risks, long-term
irritation of the oesophageal lining and genetic factors.
Risk factors for oesophageal cancer include:
1. Tobacco smoking: there is increased risk of oesophageal squamous cell
carcinoma (OSCC) in tobacco smokers compared with non-smokers.
2. Heavy alcohol consumption: heavy alcohol drinking is linked to OSCC, and
when combined with tobacco smoking, the risk dramatically increases.
3. Chronic acid reflux (gastro-oesophageal reflux disease or GORD/GERD):
long-term acid reflux from the stomach back into the oesophagus damages
the lining of the lower oesophagus and causes a condition known as Barrett’s
oesophagus. The normal squamous cells that line the oesophagus are
replaced by abnormal glandular (columnar) cells. Barrett’s oesophagus
significantly increases the risk of oesophageal adenocarcinoma.
4. Obesity, particularly abdominal obesity (excess fat around the waist), raises
the risk of adenocarcinoma by contributing to reflux and inflammation due to
increasing pressure inside the abdomen.
5. Diets: diets low in fresh fruits and vegetables and high in processed or pickled
food have been linked to higher oesophageal cancer risk in some regions.
6. Drinking very hot beverages (hotter than about 65°C), such as very hot
coffee, tea or mate, has been associated with increased risk of oesophageal
squamous cell carcinoma.
7. Chewing betel quid, a stimulant from chopped areca nut (betel nut), increases
the risk of oesophageal cancer because it contains carcinogens (cancer-
causing substances). This practice is common in China, India and some
countries in Southeast Asia and the Pacific.
8. Demographics (age, sex and location): Oesophageal cancer risk increases
with age and is most often diagnosed after the age of 60. It is more common
in men than women. Some countries in Eastern Asia and Eastern/Southern
Africa show particularly high rates, largely due to lifestyle and environmental
exposures.
9. Other medical conditions and environmental factors: certain medical
conditions contribute to higher rates of oesophageal cancers. Examples
include:
- Achalasia is a disorder in which the food pipe (oesophagus) cannot properly
move food down into the stomach because a valve called the lower. - esophageal sphincter does not open or relax as it should. Oesophageal
cancer risk is associated with achalasia. - Plummer-Vinson syndrome: In this condition, a thin “web” of tissue forms in
the upper oesophagus, which can cause difficulty with swallowing; affected
individuals may feel like food gets stuck in their throat. It is common when people have low levels of iron in their blood (iron-deficiency anaemia).
Plummer-Vinson syndrome increases the risk of developing oesophageal
squamous cell cancer. - Ionising radiation: previous exposure to ionising radiation from treatment of
breast cancer or Hodgkin lymphoma increases the risk of oesophageal
cancer.Its important to know that having one or more risk factors does not mean someone
will develop oesophageal cancer. Instead, these risk factors raise the likelihood of
getting oesophageal cancer over time.
What Are the Symptoms and Signs of Oesophageal Cancer?
Oesophageal cancer often causes no symptoms in early stages. The disease is
frequently advanced when symptoms appear.
You may experience the following symptoms if you have oesophageal cancer,
depending on the stage and location of the disease:
1. Difficulty swallowing (dysphagia): this is the most common symptom. It may
start with difficulty swallowing solid foods, which later progresses to problems
with softer foods and liquids when the tumour has grown.
2. Unintentional weight loss
3. Loss of appetite
4. Persistent indigestion, heartburn or chest discomfort that does not respond to
treatment
5. Persistent cough or hoarseness: this is due to irritation of the airway or
involvement of nearby nerves, which can lead to cough, hoarse voice, or
frequent throat clearing.
6. Vomiting or food regurgitation
7. Advanced disease symptoms: these arise at a later stage in the disease
progression or when the tumour has spread. Examples include bone pain (if
the cancer has spread to bones), shortness of breath (due to tumour spread to the lungs or aspiration) or black, tarry stools (melaena) if there is bleeding into the digestive tract.
Common non-cancerous conditions can also trigger many of these symptoms. If the
symptoms persist, seek medical advice promptly because early detection makes
oesophageal cancer more treatable.
How is Oesophageal Cancer Diagnosed?
Diagnosis involves several steps:
1. Clinical Assessment: Your doctor will ask about symptoms or risk factors that
may suggest oesophagus cancer as mentioned above. Furthermore, she/he
will examine you, including checking your weight, nutritional status and any
swollen lymph nodes.
2. Endoscopy (oesophago-gastroscopy): A thin, flexible tube with a camera at
the tip is passed through the mouth into the oesophagus and stomach. This
allows the doctor to see any narrowing, ulcers, masses, or abnormal linings.
3. Biopsy: The procedure is essential to make a definite diagnosis of cancer.
Small samples of tissue are taken from any suspicious area during
endoscopy. These are examined under the microscope by specialist doctors
called histopathologists to determine : – whether cancer is present
– the type of cancer (for example, squamous cell carcinoma or
adenocarcinoma)
– how aggressive the cells appear (grade)
– whether there are certain molecular markers (for example, HER2).
4. Staging Tests: Once oesophageal cancer is confirmed, further tests are
needed to find out how far the cancer has spread (stage). These may include:
-CT scan of the chest, abdomen and pelvis
-Endoscopic ultrasound (EUS) – combines ultrasound with endoscopy in
which case a tube attached to a camera is passed into the throat to show how
deeply the tumour has invaded the oesophageal wall and nearby lymph nodes
– PET-CT scan – can identify active cancer in lymph nodes or distant
organs.
Staging is often described using the TNM system (Tumour–Node–Metastasis) and the AJCC/UICC stage groups (stages I–IV). International guidelines such as the
NCCN Guidelines for Esophageal and Esophagogastric Junction Cancers emphasise the importance of accurate staging in planning treatment.
How Oesophageal Cancer Be Prevented?
Not all cases of oesophageal cancer can be prevented, but several practical steps
can reduce the risk of developing it, especially when started early in adulthood. The
following can help in preventing oesophageal cancer:
- Do not smoke or give up cigarette smoking and all forms of tobacco if you already do
- Do not drink alcohol or stop drinking alcohol if you already do. When combined with
smoking cessation, avoiding alcohol consumption reduces the risk of oesophageal
squamous cell carcinoma. Maintain a healthy body weight, especially avoiding abdominal obesity
Manage acid reflux and Barretts oesophagus: If you have persistent heartburn, chest discomfort, or Barrett’s oesophagus, consult your healthcare provider for appropriate treatment. Your doctor may pass a tube connected with a camera (endoscope) down into your throat. This allows the doctor to view the lining in your throat and upper stomach (surveillance endoscopy) for changes that may suggest early onset of cancer (pre-cancerous changes).
Eat plenty of fruits and vegetables daily – they contain protective antioxidants and fibre, which can give you some forms of protection against cancer.
Be careful with very hot drinks (above 65°C). Allow hot tea, coffee and other beverages to cool slightly before drinking.
Seek help early from your healthcare provider if you notice symptoms such as difficulty swallowing, persistent heartburn, unexplained weight loss or chest discomfort. You are much more likely to live longer if oesophageal cancer is detected
early than when discovered at a later stage.
What Treatment Options are Available for Oesophageal Cancer?
Treatment options available for oesophageal cancer depends on:
- The location of the cancer
- The cancer stage
- The cell type (squamous or adenocarcinoma)
- Overall health and wellbeing
- Patient preferences
Oesophageal cancer care is usually planned by a multidisciplinary team, including
surgeons, oncologists, gastroenterologists, radiologists, pathologists, dietitians, and
specialist nurses.
Examples of available treatment options include:
1. Surgery: i. Oesophagectomy – a major operation that involves the removal of
part or most of the oesophagus, typically along with a portion of the stomach.
The remaining oesophagus part is connected to the stomach or small
intestine. Surgeons take out the lymph nodes in the neck and abdomen at the
same time to check for spread and lower the risk of cancer recurrence.
ii. Endoscopic treatment – a procedure to treat for early cancer. It includes
endoscopic mucosal resection (removal of small, superficial lesions in the
oesophageal lining) or submucosal dissection – a more advanced procedure that
makes it possible to remove larger early tumours all at once.
2. Chemotherapy: Chemotherapy uses medicines that circulate in the bloodstream to
kill cancer cells. It may be used:
- before surgery (neoadjuvant),
- after surgery (adjuvant) in selected high-risk cases,
- or in advanced or metastatic disease to control symptoms and prolong life.
3. Radiotherapy – high-energy radiation is used to kill cancer cells. It is often
combined with chemotherapy (chemoradiotherapy) as definitive treatment for
squamous cell cancers or before/after surgery.
4. Targeted therapy and immunotherapy – drugs such as nivolumab and
pembrolizumab (immune checkpoint inhibitors) help the immune system to
recognise and attack cancer cells.
5. Palliative and supportive care: this form of care is done to control symptoms and
maintain quality of life when the disease has advanced.
– Endoscopic stent placement is used to keep the oesophagus open and relieve
swallowing difficulties.
- Radiotherapy or chemotherapy to shrink tumours and reduce pain.
- Nutritional support, such as soft or liquid diet advice, feeding tubes or
supplementary feeding when necessary. - Pain management, treatment of nausea, breathlessness or other distressing
symptoms. - Psychological, social and spiritual support for patients and their families.
Support and Resources
Check out the following links for more information and support on oesophageal
cancer:
1. www.cancerresearchuk.org/about-cancer/oesophageal-cancer
2. www.macmillan.org.uk/cancer-information-and-support/oesophageal-cancer
3. www.oca.org.uk (Oesophageal Cancer Awareness – UK charity)
4. www.cancer.org/cancer/esophagus-cancer
5. www.actionagainstheartburn.org.uk (for Barrett’s oesophagus and reflux-
related issues)
