Oesophageal cancer

How common is oesophageal cancer? (Epidemiology)^{1 2}

Carcinoma of the oesophagus is a common, aggressive tumour. Several histological types are seen, almost all of which are epithelial in origin. The vast majority of these tumours will be either squamous cell carcinoma (SCC) or adenocarcinoma (AC).

The incidence of AC and its precursor lesion, Barrett's oesophagus, has increased in Western populations over the past four decades; the incidence of SCC has declined in most parts of the world over the same period. SCC still accounts for the vast majority of all oesophageal cancer cases diagnosed worldwide each year.

Incidence rates in the UK are considerably higher than the EU average.

Incidence^{1 3}

• In the UK, carcinoma of the oesophagus is the 16th most common cancer in women and the 9th most common in men.

• It accounts for around 2% of all new cases of cancer in the UK.

• There are 9,400 people diagnosed with oesophageal cancer in the UK each year. It is more common in men than women. The gap is widest at age 25-29, when the age-specific incidence rate is 16 times lower in females than males. This difference narrows with unceasing age.

• It is more common in older people. In the UK, on average each year around 40 out of 100 (around 40%) of new cases are in people aged 75 and over. The peak age is 85-89 years. It is very rare in people younger than 40.

The incidence of oesophageal carcinoma varies considerably with geographical location, with high rates in Asia and Central and South Africa than in most of Europe. Within Europe, the highest rates are in Russia, France, Ireland and the UK. . AC is seen more frequently in white populations, whereas SCC is more frequent in people of African descent. There is considerable geographical variation of lower oesophageal cancer within the UK, the reason for which is being investigated.

Risk factors^{45 67}

• The use of tobacco and alcohol are strong risk factors for both SCC and AC and have a synergistic effect in this respect for SCC and additive effect for AC. Cigarette smoking is associated with a 10-fold increase in risk for SCC and a 2- to 3-fold increase in risk for AC. The relative increase in risk caused by smoking remains high for AC, even after 20 years of giving up smoking, but reduces within five years for SCC .

• Barrett's oesophagus, which is a precursor of AC. Gastro-oesophageal reflux is a risk factor for Barrett's.

• Chronic inflammation and stasis from any cause increase the risk of oesophageal SCC - eg, strictures due to caustic injury or achalasia.

• Tylosis and Plummer-Vinson syndrome are also associated with an increased risk for SCC.

• Obesity has been linked with increased risk for AC but reduced risk for SCC. Obesity increases the risk of gastro-oesophageal reflux disease (GORD), in turn increasing the risk of Barrett's oesophagus. The relationship between obesity and the rise in AC has, however, been questioned. A review of the Connecticut Tumor Registry data between 1940-2007 showed that the increase in AC seen in the 1960s predated the rise in obesity by a decade.⁸ The authors of the review propounded that this may have been linked to a decrease in the incidence of Helicobacter pylori infection or environmental factors.

• One Japanese study showed a link between oesophageal cancer and tooth loss.

• A family history of hiatal hernia is a risk factor for oesophageal adenocarcinoma, and some people appear to have a genetic predisposition to developing types of gastro-oesophageal cancers.⁹

Symptoms of oesophageal cancer (presentation)

Oesophageal cancers often present late in the progress of the disease, because approximately 75% of the circumference of the oesophagus must be involved before symptoms of 'food sticking' are experienced. As a result, approximately half of the patients who present as a result of developing symptoms, will already have an unresectable tumour or distant metastases.

Symptoms and signs of oesophageal cancer which may cause a patient to present to a doctor include:

• Dysphagia.

• Weight loss.

• Loss of appetite.

• Odynophagia.

• Hoarseness.

• Melaena.

• Retrosternal pain.

• Intractable hiccups.

• Lymphadenopathy.

When to refer¹⁰

Offer urgent, direct access upper gastrointestinal endoscopy (to be performed within two weeks) to assess for oesophageal cancer in people:

• With dysphagia; or

• Aged 55 and over with weight loss and any of the following:

  • Upper abdominal pain.

  • Reflux.

  • Dyspepsia.

Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis.

Consider non‑urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:

• Treatment‑resistant dyspepsia; or

• Upper abdominal pain with low haemoglobin levels; or

• Raised platelet count with any of the following:

  • Nausea.

  • Vomiting.

  • Weight loss.

  • Reflux.

  • Dyspepsia.

  • Upper abdominal pain; or

• Nausea or vomiting with any of the following:

  • Weight loss.

  • Reflux.

  • Dyspepsia.

  • Upper abdominal pain.

Differential diagnosis

These include:

• Oesophageal stricture from any cause.

• Compression of the oesophagus from external sources - eg, enlarged lymph glands or bronchial carcinoma.

• Achalasia.

• Gastric cancer.

• Intramural benign tumours - eg, leiomyoma.

• Metastatic tumours - most commonly from breast.

Diagnosis of oesophageal cancer (investigations)^{1112 13}

The initial investigation of a patient with symptoms suggestive of oesophageal carcinoma should include:

• FBC, U&E, LFT, glucose, CRP.

• Urgent endoscopy - with brushings and biopsy of any lesion seen. Trials are ongoing for a 'sponge-on-a-string' technology whereby a patient swallows a capsule-shaped device containing a sponge which collects cell samples. It is then extracted via a string - this may reduce the need for diagnostic endoscopy for some patients.

Other possible staging investigations include:

• CXR - looking for evidence of metastases.

• Double-contrast barium swallow.

• CT/MRI scan of the chest and upper abdomen - for staging purposes.

• Fluorodeoxyglucose positron emission tomography (FDG-PET) scan - for accuracy of staging (combined with CT).

Less commonly:

• Endoscopic ultrasound - increases accuracy of staging.

• Fine-needle aspiration - of any palpable cervical lymph node; ±

• Bronchoscopy - in high oesophageal tumours or if hoarseness or haemoptysis is present.

Stages of oesophageal cancer¹⁴

Management of oesophageal cancer¹⁵

Management will depend on the stage and may include some of the following:

• Endoscopic or radical resection of the cancer, +/- resection of any remaining Barrett's mucosa.

• Oesophagectomy.

• Lymph node dissection.

• Chemotherapy.

• Radiotherapy.

Palliation^{15 16}

Many patients will present late in the disease process with unresectable disease. For this group of patients, the emphasis will be on palliation and symptom relief.

• Radiotherapy, brachytherapy, chemotherapy, electrocautery or plasma/laser ablation may be of use (primarily in reducing tumour bulk and bleeding) and may prolong life.

• Photodynamic therapy may also be used for palliation in advanced disease.¹⁷

• Trastuzumab in combination with cisplatin/fluoropyrimidine should be considered for patients with HER2-positive oesophago-gastric junctional AC.¹⁸

• Stenting is a first-line option to assist swallowing.

• Nutritional status may be maintained by the use of liquid feeds, enteral nutrition or percutaneous endoscopic gastrotomy (PEG) tubes.

• Pain relief should be maintained at a level at which the patient experiences little, or no pain.

Prognosis of oesophageal cancer

Survival varies by stage at diagnosis - 5-year survival rates are as follows:

• Stage 1 - 65%.

• Stage 2 - 30%.

• Stage 3 - 20%.

• Stage 4 - no statistics available. 5% will survive for 4 years after diagnosis.

Prevention of oesophageal cancer ¹⁹

Reducing risk factors (obesity, smoking and alcohol) should help.

Earlier detection through screening and surveillance will improve survival rates. However, standard diagnostic tools (eg, endoscopy with biopsy) have several limitations as screening tools - including low negative predictive value and relatively high cost.

Recent introduction of the capsule sponge for diagnosis brings up the question as to whether this could be used for screening of those at high-risk, however as of December 2025 the National Screening Committee has not assessed the possibility of screening for oesophageal cancer.