Over half of the esophageal cancers appear in the upper two-thirds of the esophagus – in the cells lining the esophageal tube and about 40 percent develop in the lower third – in the glands. (Only one or two percent are rare tumors.) Generally, the cancer starts out as carcinoma of the esophagus on the surface, and then invades the surrounding tissue, often growing an obstruction, making swallowing difficult. It then spreads to the lymph nodes.
In most cases in North America, it is caused by abuses of alcohol and tobacco or long standing acid reflux. Esophageal cancer is relatively uncommon; however, in the United States, it affects about 13,000 people a year accounting for 1.5 percent of all cancers. It is most common in men over 60, smokers, drinkers, African-Americans and Caucasians with long standing acid reflux.
The most common symptom – in 90 percent of patients – is difficulty or pain in swallowing. Other symptoms are weight loss (which can be substantial), heartburn, hoarseness, pneumonia, and vocal chord paralysis. There are a number of ways to test for esophageal cancer. First a physical examination may be done. The physician may look for enlarged lymph nodes, especially over the left collarbone, and pain in the vertebrae when the spinal area is tapped. A barium swallow, a series of x-rays which shows the barium solution as it is swallowed, and a x-ray of the esophagus is important as they outline the esophagus and may reveal a narrowing of the esophagus caused by a tumor. Chest x-rays are also performed to determine if the disease has spread to other organs. Esophagoscopy (using a lighted flexible tube with a camera attached) is a key test because it provides visualization and allows sampling (biopsies) of the esophagus. Finally, CT scans of the lung and abdomen and an esophageal endoscopic ultrasound may be performed.
Surgery offers the best chance of long-term survival. Radiation therapy offers tumor control, however it is most effective on small tumors; and sometimes chemotherapy is added to radiation therapy. If a tumor is blocking the esophagus, laser therapy, photodynamic therapy or stenting may be used to create an opening so that swallowing is easier. Nutritional support with all of these procedures is necessary. Recent studies with combined radiation and chemotherapy prior to surgery are resulting in longer survival for patients diagnosed with esophageal cancer.