Oesophageal cancer
Oesophageal cancer is a serious disease, and this page does not pretend otherwise. But two things have changed substantially in the last two decades and both favour patients: early disease found at endoscopy can now often be cured without removing the oesophagus, and for advanced but operable disease, treatment given before surgery has improved survival meaningfully. The single factor that most influences outcome, beyond the stage itself, is whether treatment is planned by a specialist multidisciplinary team and the surgery performed in a unit that does it regularly.
The two main types, and how they form
Oesophageal cancer is not one disease. The two principal types arise from different cells, in different parts of the oesophagus, for different reasons.
Adenocarcinoma
Arises in the lower oesophagus and at the junction with the stomach, and is now the commoner type in Western countries. Its development is a sequence, and each step is a response to injury:
- Chronic reflux of acid and bile damages the squamous lining faster than it can repair.
- The lining is replaced by acid-tolerant columnar cells with goblet cells — Barrett's oesophagus, a protective adaptation.
- This metaplastic lining is genetically less stable. Continued injury and inflammation drive mutations — frequently in TP53 — producing low-grade then high-grade dysplasia.
- Dysplastic cells eventually breach the basement membrane: invasive adenocarcinoma.
Each step takes years. That slow tempo is precisely what makes surveillance and endoscopic treatment of the early stages worthwhile.
Risk factors follow the mechanism: long-standing reflux, Barrett's oesophagus, central obesity (which both worsens reflux and creates a pro-inflammatory metabolic state), smoking, male sex and age.
Squamous cell carcinoma
Arises in the upper and middle oesophagus from the squamous lining itself, and remains the commoner type worldwide. Here the mechanism is direct carcinogenic injury to the squamous epithelium, producing squamous dysplasia and then invasive carcinoma.
Risk factors: smoking and alcohol, which act together far more than additively; very hot drinks; diets low in fruit and vegetables; achalasia of long standing; previous caustic injury; previous radiotherapy to the chest; and head and neck cancer, which shares the same field of injury.
Why spread happens early
This anatomical point explains much of the behaviour of the disease and deserves stating. The oesophagus has no serosa — no outer containing membrane — so tumours reach adjacent structures more readily than in other parts of the gut. It also has an unusually rich, longitudinally interconnected submucosal lymphatic network, which allows lymph node spread both upward and downward, and to nodes some distance from the tumour. This is why lymph node involvement can occur with relatively thin tumours, and why surgery involves a formal lymphadenectomy rather than simply removing the tumour.
Symptoms
Early cancer causes no symptoms at all. This is the difficulty, and it is why the disease is often advanced at presentation.
- Progressive dysphagia — the cardinal symptom. Characteristically it begins with solid food, particularly meat and bread, and progresses over weeks to months to softer food and then to liquids. Progression over weeks rather than years is the feature that distinguishes it from benign causes.
- Weight loss, both from reduced intake and from the disease itself
- odynophagia — pain on swallowing
- retrosternal or back pain
- regurgitation of undigested food
- hoarseness — suggesting recurrent laryngeal nerve involvement
- anaemia, or occasionally overt bleeding
- persistent cough on swallowing, which may indicate aspiration or a fistula into the airway
- a lump in the neck (supraclavicular lymph node)
New difficulty swallowing in an adult requires endoscopy, promptly. It should never be treated as reflux without investigation.
How the diagnosis is made
Diagnosis and staging are separate tasks, and both must be complete before treatment is decided.
- Endoscopy with biopsy establishes the diagnosis and the type. Multiple biopsies are taken. The distance of the tumour from the incisor teeth and its length are recorded, as they influence the operation.
- CT of chest, abdomen and pelvis assesses local extent and identifies distant metastases — liver, lung, distant nodes.
- PET-CT is performed in patients being considered for curative treatment. It detects metastases missed on CT in a meaningful proportion and spares those patients a futile major operation.
- Endoscopic ultrasound gives the most accurate assessment of the depth of invasion (T stage) and of regional lymph nodes, with the option of fine-needle aspiration. It is particularly important in early disease, where it determines whether endoscopic treatment is appropriate.
- Laparoscopy is used for junctional and lower oesophageal tumours to detect small-volume peritoneal disease invisible on imaging.
- HER2 testing for adenocarcinoma, and increasingly PD-L1 and mismatch repair status, since these determine eligibility for targeted and immune treatments.
- Assessment of fitness — lung function, cardiac assessment, nutritional state — which carries as much weight as the stage in deciding what treatment is appropriate.
Treatment
Treatment depends on the stage, the type, the position, and the patient's fitness. Decisions are made in a specialist multidisciplinary meeting.
Very early disease: endoscopic treatment
Tumours confined to the mucosa, without adverse features, carry a low risk of lymph node involvement and can be cured endoscopically.
- Endoscopic mucosal resection or submucosal dissection removes the lesion intact, providing both treatment and accurate staging of depth.
- Radiofrequency ablation then eradicates any remaining Barrett's segment.
If the specimen shows deeper invasion into the submucosa, or lymphovascular invasion, or poor differentiation, the risk of node involvement rises and surgery is then recommended. This staged approach — resect, examine, decide — spares many patients an oesophagectomy.
Locally advanced, operable disease
Surgery alone is inadequate for most tumours that invade beyond the submucosa or involve lymph nodes. Standard practice is multimodal:
- Perioperative chemotherapy — given before and after surgery, the usual approach for adenocarcinoma, particularly at the junction.
- Neoadjuvant chemoradiotherapy — chemotherapy and radiotherapy before surgery, with strong evidence of survival benefit, and particularly effective in squamous carcinoma.
- Adjuvant immunotherapy is now given to patients who have residual disease in the resected specimen after neoadjuvant chemoradiotherapy.
Surgery: oesophagectomy
The operation removes the tumour with a margin, together with the regional lymph nodes, and reconstructs the swallowing passage — usually by forming a tube from the stomach and drawing it up into the chest or neck.
- Ivor Lewis (abdominal and right chest approach, anastomosis in the chest) — the standard for lower oesophageal and junctional tumours.
- McKeown (abdomen, chest and neck, anastomosis in the neck) — for more proximal tumours.
- Transhiatal — without thoracotomy, for selected patients.
Minimally invasive and robotic approaches reduce respiratory complications and shorten recovery compared with open surgery, with equivalent oncological results, and are now standard in specialist units.
The volume relationship is one of the most consistent findings in surgery: mortality and long-term survival after oesophagectomy are significantly better in high-volume units with specialist teams. This is a legitimate and important question for a patient to ask.
Squamous carcinoma of the upper oesophagus
Definitive chemoradiotherapy, without surgery, is the standard treatment for cervical oesophageal squamous carcinoma, and achieves comparable results while preserving the larynx and the oesophagus.
Advanced and incurable disease
Where cure is not achievable, treatment aims at length and quality of life, and this is real treatment, not the absence of it.
- Chemotherapy, with immunotherapy added according to PD-L1 status, and targeted treatment for HER2-positive tumours
- Self-expanding metal stent — restores swallowing rapidly, usually within a day, and is the most immediately effective intervention for dysphagia
- Palliative radiotherapy, including brachytherapy, for dysphagia and bleeding
- Nutritional support, often via a feeding jejunostomy
- Early specialist palliative care involvement, which improves both quality of life and, in some studies, survival
Recovery after oesophagectomy
This is a major operation and patients deserve a frank account of it. Hospital stay is typically eight to fourteen days, often including a period in critical care. Recovery to normal activity takes two to three months, and to full strength often six.
Lasting changes are the rule rather than the exception, and are better anticipated than discovered:
- eating smaller meals more frequently, permanently
- weight loss of the order of ten per cent, which stabilises
- reflux, particularly at night, requiring a raised bed head and medication
- dumping symptoms after sugary meals
- early satiety
- anastomotic stricture in a proportion, readily treated by dilatation
A specialist dietitian is not an optional extra in this pathway; nutritional support before, during and after treatment materially affects outcome.
Follow-up
Regular clinical review with attention to nutrition and symptoms, with imaging and endoscopy as indicated. Most recurrences occur within the first two to three years. Vitamin B12 and iron require monitoring after gastric conduit reconstruction.
When to seek an opinion
New or progressive difficulty swallowing at any age warrants endoscopy without delay. So does unexplained weight loss, food sticking, persistent vomiting, or anaemia. Long-standing reflux — particularly over many years, in a man over fifty, with other risk factors — is a reason to have an endoscopy performed once, to establish whether Barrett's oesophagus is present.
Common questions
I have trouble swallowing. Does that mean cancer?
Not necessarily — there are several benign causes, including narrowing from reflux and muscle disorders. But difficulty swallowing that has come on over weeks and is getting worse, especially with weight loss, needs an endoscopy promptly. Most people investigated do not have cancer, and those who do are far better served by finding it early.
Is oesophageal cancer curable?
Yes, when it is caught before it has spread. Very early tumours can be cured by removing them through an endoscope, without an operation. More advanced but localised disease is treated with chemotherapy or chemoradiotherapy followed by surgery, and a significant proportion of patients are cured. Outlook depends heavily on stage, which is why the staging tests are done thoroughly before anything else.
Why do I need chemotherapy before the operation rather than after?
Because treatment given first shrinks the tumour, making complete removal more likely, and treats cells that may already have spread but cannot yet be seen. This approach has been shown to improve survival compared with surgery alone, and you are also better able to tolerate it before a major operation than afterwards.
Will I be able to eat normally after surgery?
You will eat, but differently. The stomach is reshaped into a tube to replace the gullet, so it holds less. Most people settle into six or more small meals a day, avoid lying flat after eating, and lose some weight which then stabilises. A specialist dietitian works with you throughout, and this part of the care matters as much as the operation.
Does the whole oesophagus have to be removed?
Not always, and not at all for very early tumours, which are removed through an endoscope. When surgery is needed, the affected portion and the lymph nodes around it are removed and the remainder is joined to a tube made from the stomach.
Does it matter where I have the operation?
It does, more than for almost any other operation. Results are consistently better in units that perform oesophagectomy regularly, with specialist anaesthetic, critical care, dietetic and physiotherapy teams. It is entirely reasonable to ask how often the unit performs this operation.
If it cannot be cured, can anything be done about the swallowing?
Yes, and quickly. A stent placed through the endoscope opens the narrowed section and usually restores swallowing within a day. Radiotherapy and chemotherapy can also relieve symptoms and control the disease. Treatment to keep you comfortable and eating is active treatment, not giving up.
My father had it. Should I be checked?
Most oesophageal cancer is not inherited. What is worth acting on is your own risk profile — long-standing heartburn, being overweight, smoking, heavy alcohol use. If you have had reflux symptoms for many years, an endoscopy to look for Barrett's oesophagus is a reasonable discussion to have.
Related conditions
Other conditions of the oesophagus covered on this site:
- Gastro-oesophageal reflux disease (GORD) and hiatus hernia
- Paraoesophageal hernia
- Achalasia
- Barrett's oesophagus
- Oesophageal diverticulum (Zenker's and epiphrenic)
- Benign tumours of the oesophagus
- Oesophageal perforation and Boerhaave syndrome
This page provides general information and does not replace an individual medical consultation. Assessment and treatment are decided for each patient after review of their history, examination, investigations and discussion in a multidisciplinary meeting.