Esophageal Cancer

Scott Holmes

an illustration of the anatomy of a colon

Driven by obesity (which leads to GERD) and a decrease in the occurrence of a stomach infection (H. pylori) that reduced the acidity of stomach juice, esophageal cancer has become the fastest rising cancer in Caucasian men in the United States. The experts at the Baylor St. Luke's Medical Center Dan L. Duncan Comprehensive Cancer Center specialize in the prevention, diagnosis and treatment of esophageal cancer. The Esophageal Cancer Center offers a comprehensive array of services that are tailored to address your (or your loved one’s) individual needs. Our internationally recognized gastroenterologists, medical oncologists, radiation oncologists, thoracic surgeons, radiologists and nurses will guide you every step of the way from diagnosis through discussions of tailored treatment options for you. If you have questions or want to make an appointment, call (713) 798-2262.

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What You Need to Know

The esophagus is a muscular tube that moves food and liquids from your mouth to your stomach. In esophageal cancer, cancer starts on the inner lining of the esophagus and spreads outwards through the muscular layers of the esophagus. The most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma.

Risk Factors and Symptoms for Esophageal Cancer

The American Cancer Society’s estimates about 22,070 new esophageal cancer cases will be diagnosed in 2025.

Obesity, chronic GERD, Barrett’s esophagus, smoking, heavy alcohol use, and certain esophageal conditions (achalasia) increase the risk of esophageal cancer. Talk with your doctor if you think you may be at risk or if you recognize any signs and symptoms of esophageal cancer, which includes feeling like food is sticking in your chest, weight loss, chest pain, and worsening heartburn.

Preventative steps can help you avoid esophageal cancer. These include eating a healthy diet, maintaining a healthy weight and limiting smoking and alcohol use. It is important to be aware of risk factors that can increase your chances of getting esophageal cancer, which include:

Gastroesophageal reflux disease (acid reflux)
Barrett's esophagus
Obesity
Achalasia (condition where the muscle at the lower end of the esophagus does not relax properly)
Alcohol use
Tobacco use
Plummer-Vinson syndrome
Workplace exposures
Burns to the esophagus
History of other cancers
HPV (human papilloma virus)

Be on the lookout for any of the following, especially if you are in a high risk group:

Food sticking when you swallow
Chest pain
Weight loss
Chronic cough and hoarseness
Vomiting
Hiccups
Pneumonia
Bone pain
Bleeding into the esophagus

Diagnostic Techniques

Currently, there are no blood tests to diagnose esophageal cancer. While imaging studies, such as a barium esophagram or CT scan may show an abnormality, the diagnosis of esophageal cancer requires an endoscopy and biopsy. If cancer is detected, additional tests are needed to determine the extent of spread, called clinical staging.

Tests and procedures for the diagnosis and evaluation of esophageal cancer include an endoscopic exam and imaging tests (CT and/or PET scans).

Endoscopy (a flexible esophagogastroduodenoscopy or EGD) is essential for the evaluation of esophageal cancer. During an endoscopy, you doctor passes a flexible, narrow tube equipped with a small video lens down your throat and into your esophagus while you are sedated. This procedure is essential for allowing your physicians to understand how much of your esophagus (and possibly stomach) are involved with cancer and to biopsy areas of concern. Especially for smaller, early-stage cancers, your doctors may also recommend an endoscopic ultrasound (EUS) to examine how deep the cancer spreads into the wall of the esophagus and whether there are abnormal appearing lymph nodes.

Currently in the United States, esophageal cancer screening (finding cancer before symptoms develop) for the general public is not recommended. However, people who a have high risk of esophageal cancer may be considered for an endoscopic screening exam.

If cancer is seen on a biopsy, additional imaging studies (a CT scan or PET scan) or minor procedures (EUS and/or staging laparoscopy) are needed. These studies called clinical staging help your doctors understand the extent of cancer spread, establish the cancer stage (I, II, III or IV), and allow them to establish a personalized treatment plan.

Staging for Esophageal Cancer

As is the case for all other cancers, treatment of, and survival from esophageal cancer depends on its stage. Cancer staging depends on information about the:

Tumor (T stage)
Lymph nodes (N stage)
Spread to the rest of your body (M stage)
These 3 pieces of information are combined to give a cancer stage (I through IV).

In order to provide you with the best treatment possible, staging must be as accurate as possible. Staging may include a combination of imaging studies and minor procedures, depending on your potential treatment plan.

Computed tomography (CT) or positron emission tomography (PET)/CT
Endoscopic ultrasound (EUS)
Diagnostic laparoscopy

These methods complement each other. Together, they provide the most current accurate assessment of the stage of your cancer and help us individualize your treatment.

A staging procedure includes multiple small procedures. To provide you with efficient care, all the procedures are performed on the same day during one anesthesia setting while you are asleep.
These procedures include:

Bronchoscopy
Esophagogastroduodenoscopy (EGD)
Staging laparoscopy with or without jejunostomy feeding tube placement
Long-term access port placement

A staging laparoscopy procedure allows us to examine the tumor closely. We will make four or five small incisions in your abdomen and fill it with carbon dioxide to push the abdominal wall away from the organs so that the surgeon can see them clearly and examine the tumor.

First, we will determine whether the tumor has spread beyond the tissues that we can remove during an esophagectomy, such as those from the liver, the inner lining of the abdomen (the peritoneum), or the fatty apron of tissue that drapes off the lower edge of your stomach (the omentum). We will also look for cancerous fluid inside the abdomen (malignant ascites). Patients with cancer that has spread to these areas are usually not candidates for an esophagectomy. These cancers are better treated with chemotherapy. During this inspection, we will occasionally find evidence of cancer spreading that was missed with a PET/CT.

Second, we will look for involvement of the tumor with surrounding structures and for large, bulky lymph nodes. Finally, we will look at the surface of the stomach to determine whether or not the stomach can be used to make a new esophagus. This will be necessary if you undergo an esophagectomy. Depending on what we see, we may or may not perform biopsies.

Customized Treatment Plans for Esophageal Cancer

Cancers of the esophagus are uniquely challenging to treat, for two important reasons. First, esophageal cancers are relatively uncommon in the United States, and many clinicians will not have experience treating individuals with these tumors with the same frequency as they do other tumor types. Second, treatment of these cancers require a complex coordination of care between four different doctors: a thoracic surgeon, gastroenterologist, radiation oncologist, and medical oncologist.

The esophageal cancer group at the NCI-Designated Dan L Duncan Comprehensive Cancer Center has put together a focused team of specialists who provide coordinated, innovative services for prevention, detection, and treatment for esophageal cancer. Members of the Esophageal Cancer Center work in concert to create an individualized treatment plan upfront, so that the right combination and sequence of therapies can be recommended to ensure the best possible outcome for you, the patient.

Treatment may include a combination of chemotherapy, targeted therapy, immunotherapy, radiation therapy, surgery and/or endoscopic removal.

Patients also have access to National Cancer Institute-sponsored esophageal cancer clinical trials.

Treatment options depend on the following:

The patient’s general health
The stage of the cancer (whether it affects part of the esophagus, involves the whole esophagus, or has spread to other places in the body)
Whether the tumor can be completely removed by surgery

Procedures for the evaluation of esophageal cancer include: