Esophageal cancer is the abnormal growth of cells in the esophagus, the tube that carries food and drink from your throat to your stomach. The normal lining of the esophagus is called squamous epithelium, a cellular lining that is found in the mouth, throat and the lung. The junction of the esophagus, as it enters the beginning of the stomach is lined by a different type of cellular structure that contains many glands or structures that secrete various chemicals. If a cancer of the esophagus arises from that portion that lines the tube before it enters the stomach, the cancer is called squamous cell carcinoma. If it arises from the glandular portions of the esophagus, it is called adenocarcinoma (cancers of glandular structures).

There are two types of esophageal cancer:

• Squamous cell carcinoma starts in the cells that line the esophagus. This type of esophageal cancer can occur anywhere in the esophagus. In the past, this type of esophageal cancer was the most common. Over the past few decades, adenocarcinomas have accounted for many new cases of esophageal cancer.



• Adenocarcinoma starts in the lower portion of the esophagus near the opening to the stomach. It starts when cells in the lining transform into glandular type cells, a condition called Barrett's esophagus.

Esophageal cancer is common in Asia, Africa and Latin America, but less common in the United States. However, the number of cases of adenocarcinoma of the esophagus is increasing faster than almost all other cancers in the United States. Many experts have associated this increase with a regurgitation of the stomach contents into the lower portion of the esophagus, so called gastroesophageal reflux disease or GERD. No one is certain what causes esophageal cancer, but risk factors include the following:

• Age � Most people who develop esophageal cancer are over 50.



• Sex � Both types of esophageal cancer occur about three times more often in men than women.



• Race � Squamous cell esophageal cancer is three times more common among African-Americans than whites. However, Caucasians have a higher incidence of adenocarcinomas of the lower esophagus than African-Americans.



• Tobacco use � Tobacco consumed in any form increases the risk of esophageal cancer. The longer you smoke and the more you smoke each day, the greater the risk. This is primarily true for squamous cell esophageal cancer. Patients that develop esophageal cancer may also be at risk of developing cancer of the head and neck area, also related to tobacco use.



• Alcohol consumption � Chronic or excessive consumption of alcohol, especially when combined with tobacco use, increases the risk. Again, this is primarily true for squamous cell esophageal cancer. Consumption of hard liquor, rather than beer and wine, may have a stronger association, although it is the quantity of consumption that is most important. Some research suggests that the metabolism of alcohol may be different among individuals who develop esophageal cancer compared to those who drink and do not develop this cancer.



• Barrett's esophagus � Irritation caused by chronic acid reflux is believed to cause the cells at the bottom of the esophagus to transform into glandular cells similar to cells in the stomach lining. These glandular cells are more likely to become cancerous. This is the strongest known risk factor for cancer of the lower esophagus, adenocarcinoma.



• Chemical irritation � Damage to the esophagus from swallowing lye, most often during childhood, or from prior radiation increases the risk of esophageal cancer. Chemical irritation also can occur in a condition called achalasia, where part of the esophagus is dilated (expanded) and collects partially digested foods. This condition is also associated with a loss of the muscular ability of the esophagus to propel food into the stomach, leading to food accumulation and widening of the esophagus.



• Diet � A diet low in fruits and vegetables and certain minerals and vitamins has been associated with a higher risk of esophageal cancer. Nitrates in foods and fungal toxins from pickled vegetables also have been associated with esophageal cancer.



• Medical conditions � Two conditions are associated with a higher risk of esophageal cancers: Plummer-Vinson, also called Paterson-Kelly syndrome, and tylosis. Plummer-Vinson is the presence of small weblike projections in the tubular portion of the esophagus, so called esophageal webs with iron deficiency anemia. Tylosis is a condition associated with excessive keratin formation (hyperkeratosis) on the palms and soles of the feet. Both conditions may be associated with an increased risk of esophageal cancer.

Early esophageal cancer may not cause any symptoms. As the cancer progresses, it usually causes one or more of the following symptoms:

• Difficult or painful swallowing or difficulty swallowing only solid foods (called dysphagia or odynophagia). Often, patients will complain that the food feels "stuck" in the middle of the chest, just behind the breast bone.
• Pain in the chest or between the shoulder blades
• Frequent heartburn or acid reflux
• Severe weight loss
• Hoarseness or chronic cough
• Vomiting
• Coughing up blood

Other conditions can cause these symptoms. If you experience any of these, you should see your doctor. If you have chest pain or vomit blood, seek medical attention immediately.

If it is not detected, esophageal cancer will continue to grow and can spread to almost any part of the body. The chance of survival increases greatly if the disease is detected early.

How long treatment lasts and what kind of treatments given will depend on such factors as your age and general health, how advanced the cancer is, and how well your body responds to and is able to tolerate treatment. Treatments can take several months to complete. If surgery is done, the recovery period typically lasts at least three to four weeks and can be longer.

While some risk factors for esophageal cancer can't be avoided, you can take steps to decrease your risk:

• Don't use tobacco in any form. If you smoke or use smokeless tobacco, get the help you need to stop.
• Never consume anything that may damage your digestive tract.
• If you drink alcohol, drink in moderation. Most experts recommend that women have no more than one drink a day and that men have no more than two drinks a day.
• If you suffer from heartburn, discuss with your doctor how to avoid heartburn and ways to treat it, if necessary.

If you suffer from chronic reflux or heartburn symptoms, an esophagoscopy may be done to look for Barrett's esophagus. If you have Barrett's esophagus, some doctors recommend periodic exams or biopsies to look for abnormalities before they develop into cancer.

Treatment for esophageal cancer depends on the size and location of your tumor, your symptoms and your general health. Many different treatments and combinations of treatments may be used. Your team of specialists may include a surgeon, a gastroenterologist (a specialist in diagnosing and treating disorders of the digestive system), a medical oncologist (a specialist in treating cancer) and a radiation oncologist (a specialist in using radiation to treat cancer). Other testing may also be required before treatments begin to determine how well your heart and kidneys are functioning.

Here are the key treatments for esophageal cancer:

• Surgery � Removing the tumor and affected tissue offers the best chance to cure esophageal cancer. Usually, the surgeon removes all or a portion of the esophagus and the neighboring lymph nodes to prevent the cancer from spreading. Sometimes, the upper part of the stomach also is removed. The surgeon then uses the remaining portion of the stomach or a part of the intestine to reconnect the digestive tract, so that you can swallow. This is very intensive surgery and requires that the patient be able to tolerate this approach. Recently, modifications using techniques that are minimally invasive may be considered in the appropriate patient. Another important consideration is to select an institution or surgeon who has done a large number of procedures for esophageal cancer. The short-term side effect rate may be lessened when treatment is given in hospitals that do many procedures, as opposed to performing few.



• Chemotherapy � There are many new chemotherapeutic agents and other types of chemical treatments that have been introduced over the past five years that show some promise in increasing the success rates.



• Radiation therapy � This treatment uses high-energy rays to kill cancer cells. The radiation may come from a machine outside the body (external radiation) or from radioactive elements placed in or near the tumor (internal radiation). Radiation therapy may be done instead of surgery, either alone or in combination with chemotherapy, especially if the size or location of the tumor makes surgery difficult. Radiation therapy may be combined with chemotherapy to shrink the tumor before doing surgery. If the tumor can't be removed by surgery or destroyed by radiation therapy, radiation may help to ease pain and make swallowing easier.

In general, the determination(s) of whether to use surgery, chemotherapy, or radiation therapy, alone or in combination, will ultimately depend upon the stage (assessment of the extent of the cancer) of the cancer as determined by the tests listed above.

In making a decision about what treatment to recommend, your cancer team will weigh the benefits of surgery against the risks of this serious operation, which has many potential complications. For many people, radiation therapy alone or in combination with chemotherapy may offer the same chance of survival as surgery. In addition, there are other options to improve symptoms, including:

• A stent (small wire mesh) placed into the esophagus. This is done to bypass the blockage resulting from the cancer, thus allowing the patient to eat properly.
• A laser to reduce the size of a tumor, which can prevent blockage and improve swallowing.
• A simpler surgery, in which feeding tubes are inserted into the stomach or intestine for nutrition and to avoid swallowing problems.

See your doctor if you experience any characteristic symptoms of esophageal cancer, such as difficulty swallowing, weight loss or vomiting. If you have chest pain or vomit blood, seek medical attention immediately. If you have the sensation that food is sticking in the swallowing tube, you should contact your physician as well. Individuals who have been diagnosed with GERD, too, should seek consultation with a gastroenterologist, to determine whether any pre-cancerous conditions are present in the lower esophageal � upper stomach area.

Once cancer has been diagnosed, your doctor will conduct tests to determine what stage your cancer has reached. The stages are labeled 0 to IV. The higher the stage number, the further the cancer has spread. For example, in stage 0, the cancer is confined to the superficial lining of the esophagus. In stage I, the cancer has not invaded the outer muscle layer of the esophagus.

Surgery to remove the tumor offers the best chance for cure. However, cure is relatively rare, since many patients have already experienced spread to the surrounding lymph node tissue or other organs, even when the cancer is first diagnosed. If the disease is caught early, the five-year survival rate is much higher � 75% for patients diagnosed in stage 0 and 40% to 50% for those diagnosed in stage I. Most esophageal cancer is diagnosed at the more advanced stages when the five-year survival is only about 15% to 20% or less. With or without surgery, chemotherapy and radiation therapy can help to improve the quality of life and prolong survival, even in advanced stages.

National Cancer Institute (NCI)
U.S. National Institutes of Health
Public Inquiries Office
Building 31, Room 10A03
31 Center Drive, MSC 8322
Bethesda, MD 20892-2580
Phone: 301-435-3848
Toll-Free: 1-800-422-6237
TTY: 1-800-332-8615
E-Mail: cancergovstaff@mail.nih.gov
http://www.nci.nih.gov/

American Cancer Society (ACS)
1599 Clifton Road, NE
Atlanta, GA 30329-4251
Toll-Free: 1-800-227-2345
http://www.cancer.org/

Cancer Research Institute
681 Fifth Ave.
New York, NY 10022
Toll-Free: 1-800-992-2623
E-Mail: info@cancerresearch.org
http://www.cancerresearch.org/