Oesophageal cancer

What is oesophageal cancer?

Oesophageal cancer happens when abnormal cells in your oesophagus, the long muscular tube that carries food from your throat to your stomach, grow out of control and form a tumour. It often causes no symptoms in its early stages, which is one reason it tends to be picked up later than some other cancers.

What are the symptoms of oesophageal cancer?

Oesophageal cancer can be hard to spot early on. Many early cases are only found when someone sees a doctor about long-term acid reflux and a camera test happens to pick up a tumour that hasn't caused symptoms yet.

Early symptoms can include:

• pain when swallowing
• indigestion or heartburn that doesn't go away
• a feeling of pressure, pain or burning in your chest or throat
• a reduced appetite
• a persistent cough, hoarseness or hiccups.

As the cancer grows, further symptoms can develop, including:

• difficulty swallowing, especially solid food, which may feel like food is stuck in your throat or chest
• unintended weight loss
• vomiting, or bringing back up food
• vomiting or coughing up blood, or black, tar-like stools, which can be signs of internal bleeding
• tiredness and weakness from anaemia (a low red blood cell count)
• pain in your throat, back, behind your breastbone or between your shoulder blades
• chest infections, if food or liquid enters your lungs because swallowing has become difficult.

These symptoms are usually caused by something other than cancer, such as reflux, ulcers or a hiatus hernia. But because they overlap so closely with oesophageal cancer, it's worth having them checked rather than assuming they'll settle on their own.

What are the causes of oesophageal cancer and who is at risk?

Doctors don't know the exact cause of oesophageal cancer, but they've identified several factors that raise your risk.

Personal factors linked to higher risk include:

• being aged 55 or over
• being male
• your race, which can influence which type you're more likely to develop: Black and Asian people are more likely to have squamous cell oesophageal cancer, while white people more often have adenocarcinoma
• a family history of oesophageal cancer.

Other health conditions that increase your risk include:

• Barrett's oesophagus and long-term acid reflux, also called gastro-oesophageal reflux disease (GORD)
• chronic heartburn
• achalasia, a condition affecting how your oesophagus moves food
• a history of head and neck cancer
• human papillomavirus (HPV) infection
• living with overweight or obesity.

Lifestyle factors that raise your risk include:

• long-term or heavy alcohol use
• smoking, including smokeless tobacco
• a diet low in fruit and vegetables
• drinking very hot drinks often
• long-term exposure to certain chemicals at work, such as dry-cleaning solvents, mineral spirits, paint and varnish.

You may be able to lower your risk by keeping to a healthy weight, cutting down on alcohol and tobacco, asking your doctor about HPV vaccination, and using protective equipment if your job involves long-term chemical exposure. If you have Barrett's oesophagus or achalasia, your doctor may recommend a regular camera test (endoscopy) to check for early changes.

Are there different types of oesophageal cancer?

There are two main types of oesophageal cancer, and which one you have affects where in your oesophagus it develops:

• Adenocarcinoma, the more common type, which develops in the mucus-producing tissue that helps you swallow and usually affects the lower part of your oesophagus. It's closely linked to acid reflux and Barrett's oesophagus.
• Squamous cell carcinoma, which begins in the flat cells lining your oesophagus and typically affects the upper and middle parts.

How is oesophageal cancer diagnosed?

Your doctor will start with a physical examination and ask about your symptoms and medical history. They may then arrange:

• a barium swallow, an X-ray test that checks for tumours in your oesophagus
• a CT scan, to look for cancer in your chest and abdomen
• an upper endoscopy, a camera test that looks inside your oesophagus, sometimes combined with an endoscopic ultrasound
• a biopsy, where a small piece of tissue is removed, often during the endoscopy, and checked for cancer cells.

Your results are used to stage the cancer, which shows whether it's contained within the oesophagus (localised), has reached nearby lymph nodes or tissue (regional), or has spread further, to organs such as your bones, brain, liver or lungs (distant). Your doctor will also grade the tumour: low-grade tumours grow slowly and tend to be less aggressive, while high-grade tumours divide quickly and can behave more aggressively. Staging and grading together shape your treatment plan.

How is oesophageal cancer treated?

Surgical treatment

Surgery to remove the cancer is a common treatment, particularly for early-stage disease. Options include:

• oesophagectomy, which removes some or most of your oesophagus and surrounding tissue. Your surgeon reconnects the healthy remaining oesophagus to your stomach, sometimes using part of your intestine or a plastic tube to bridge the gap, and nearby lymph nodes are usually removed and checked for cancer at the same time
• multivisceral resection, a more complex operation for cancer that has grown into nearby organs, where the tumour is removed along with the affected surrounding organs or structures
• endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR), minimally invasive procedures using a camera passed through your mouth to remove small or early tumours without open surgery.

If a tumour is partly blocking your oesophagus, your care team may place an expandable metal stent, or tube, inside it to help keep it open and let you swallow more easily.

Non-surgical treatment

Several non-surgical treatments can be used alone, together, or alongside surgery:

• radiation therapy, delivered from outside your body or, less often, from a radioactive source placed near the tumour. It can shrink a tumour before surgery, clear remaining cells afterwards, or ease symptoms if the cancer has spread. A plastic tube may be placed in your oesophagus to keep it open during treatment
• chemotherapy, which uses drugs to stop cancer cells growing, often alongside radiation therapy (chemoradiation) before or after surgery, or on its own if the cancer has spread
• endoscopic laser therapy or electrocoagulation, which destroy cancerous tissue using a laser or electrical current, often used if a tumour is blocking your oesophagus
• photodynamic therapy, which uses a light-activated medicine to trigger a reaction that kills cancer cells, for early-stage cancer or to help manage symptoms
• targeted therapy, using drugs designed to attack specific proteins or genes that help particular cancer cells grow
• immunotherapy, which helps your immune system recognise and attack cancer cells. It may be offered before or after surgery, or if surgery isn't possible because the cancer has spread.

You may also be offered nutritional support during treatment, such as a feeding tube, since swallowing difficulties can make it hard to eat and keep your strength up. You may want to think about taking part in a clinical trial at any stage of treatment - these test new approaches to treating, diagnosing or easing the symptoms of cancer, and aren't only for advanced disease.

When should I see a doctor?

Talk to your doctor if you notice:

• trouble swallowing, especially if it's getting worse
• persistent heartburn or chest discomfort
• unexplained weight loss or loss of appetite
• vomiting, or bringing back up undigested food
• black stools or other signs of bleeding
• hoarseness, hiccups or a cough that won't go away
• feeling unusually tired or weak.

These symptoms don't always mean you have oesophageal cancer, but getting them checked early gives you the best chance of catching any problems sooner and having effective treatment.