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. (See the next section for risk factors that can affect these chances.)
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 carcinoma is 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 two most common types of esophageal cancer are:
Adenocarcinoma: In the United States, adenocarcinoma is the most common type of esophageal cancer. Usually, these tumors are found in the lower part of the esophagus, near the stomach. Adenocarcinoma of the esophagus may be related to having acid reflux (the backward flow of stomach acid), having a disease of the lower esophagus known as Barrett esophagus, or being obese.
Squamous Cell Carcinoma (SCC): In other parts of the world, SCC is the most common type of esophageal cancer. Usually, SCC tumors are found in the upper part of the esophagus. SCC of the esophagus may be related to being a heavy drinker of alcohol or smoking tobacco.
Risk Factors for Esophageal Cancer:
- 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. 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: 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.
- Alcohol: 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) have a higher chance of getting adenocarcinoma of the esophagus. 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.
Symptoms of Esophageal Cancer:
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.
- Trouble swallowing: 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.
- 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. 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.
- Chronic cough
- 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.
Staging tests can show the stage (extent) of esophageal cancer, such as whether cancer cells have spread to other parts of the body.
When cancer of the esophagus spreads, cancer cells are often found in nearby lymph nodes. Esophageal cancer cells can spread from the esophagus to almost any other part of the body, such as the liver, lungs, or bones.
CT scan: Your doctor may order a CT scan of your chest and abdomen. An x-ray machine linked to a computer will take a series of detailed pictures of these areas. You’ll receive contrast material by mouth and by injection into a blood vessel in your arm or hand. The contrast material makes abnormal areas easier to see. The pictures can show cancer that has spread to the liver, lungs, bones, or other organs.
PET scan: Your doctor may use a PET scan to find cancer that has spread. You’ll receive an injection of a small amount of radioactive sugar. A machine makes computerized pictures of the sugar being used by cells in the body. Because cancer cells use sugar faster than normal cells, areas with cancer cells look brighter on the pictures. The pictures can show cancer that has spread to the lymph nodes, liver, or other organs.
EUS: An EUS (endoscopic ultrasound) can show how deeply the cancer has invaded the wall of the esophagus. It can also show whether cancer may have spread to nearby lymph nodes. Your doctor will pass a thin, lighted tube (endoscope) through your mouth to your esophagus. A probe at the end of the tube sends out high-energy sound waves. The waves bounce off tissues in your esophagus and nearby organs, and a computer creates a picture from the echoes. During the exam, the doctor may take tissue samples of lymph nodes.
National Cancer Institute
American Cancer Society