Oesophageal Cancer: Symptoms, Causes and Treatments

Oesophageal cancer is notoriously difficult to detect in its early stages, as symptoms often remain unnoticed until the disease has progressed significantly. This delayed onset of visible signs makes early diagnosis challenging, and many individuals may not recognize the warning symptoms until the cancer is more advanced.

There are two primary types of oesophageal cancer: adenocarcinoma, which typically develops in the lower third of the oesophagus, and squamous cell carcinoma, which usually arises in the upper two-thirds. Common symptoms include difficulty swallowing (dysphagia), chest pain, unexplained weight loss, and persistent heartburn.

This cancer is more commonly found in men, especially those with a history of smoking or heavy alcohol consumption. However, early detection can greatly improve the chances of successful treatment.

This guide provides a comprehensive overview of oesophageal cancer—highlighting the early warning signs, and examining the range of treatment options available, including surgery, chemotherapy, radiation therapy, and newer immunotherapy approaches.

What is Oesophageal Cancer?

Oesophageal cancer develops in the oesophagus, a long muscular tube that connects the throat to the stomach. This cancer begins when cells in the inner lining (mucosa) of the oesophagus develop changes in their DNA, causing them to multiply uncontrollably and eventually form tumours.

Oesophageal Cancer Symptoms

Detecting oesophageal cancer early is difficult, as symptoms often do not appear in the initial stages. In many cases, signs only become noticeable once the disease has progressed significantly.

Difficulty swallowing (dysphagia) is typically the earliest and most common symptom. At first, individuals may struggle to swallow solid foods such as bread or meat. As the tumour grows, this difficulty gradually worsens. Many people adapt by changing their eating habits—taking smaller bites, chewing more thoroughly, or drinking water to help move food down the oesophagus. Over time, they may switch to softer foods, and in severe cases, may be limited to a liquid diet.

Painful swallowing (odynophagia) can develop when the tumour becomes large enough to obstruct food passage. This pain usually occurs a few seconds after swallowing, as the food encounters resistance while passing through the narrowed section of the oesophagus.

Chest discomfort manifests in various forms, including:

• Pain behind the breastbone or between the shoulder blades
• Pressure or burning sensation in the chest
• Throat pain

Other significant symptoms include:

• Vomiting or coughing up blood
• Persistent heartburn or worsening indigestion
• Hoarseness or chronic cough
• Black tar-like stools (indicating bleeding into the oesophagus)
• Regurgitation of food
• Anaemia, causing weakness and fatigue
• Unintentional weight loss 
• Persistent hiccups
• Pneumonia
• recent onset upper backache

Causes of Oesophageal Cancer

Several lifestyle factors play crucial roles in raising oesophageal cancer risk:

• Tobacco use stands as a major contributor, doubling the risk of adenocarcinoma for those who smoke a pack of cigarettes daily. The link to squamous cell carcinoma proves even stronger.
• Alcohol consumption significantly increases risk, especially for squamous cell carcinoma. Notably, combining smoking and drinking elevates the risk substantially more than either habit alone.
• Eating habits matter greatly. Research shows that eating too fast, drinking hot beverages, consuming hard foods, and overeating all correlate strongly with increased oesophageal cancer risk.
• Gastroesophageal reflux disease (GERD) and Barrett's oesophagus raise adenocarcinoma risk, particularly for those with frequent symptoms.
• Obesity increases risk partly by promoting reflux.
• Diet choices influence risk—processed meat consumption may increase it, whereas fruits and vegetables likely provide protection.

Additional risk factors include:

• Achalasia, where the lower oesophageal sphincter doesn't relax properly
• Tylosis, a rare inherited condition
• Plummer-Vinson syndrome, characterised by oesophageal webs
• Occupational exposure to certain chemicals like dry cleaning solvents

Complications of Oesophageal Cancer

• Blockage of the oesophagus presents as one of the most common complications. The growing tumour gradually narrows the oesophageal passage, making it difficult or even impossible for food and liquids to pass through. This obstruction occurs because oesophageal cancer typically grows rapidly, with the flexible oesophagus expanding around the tumour until it can no longer stretch further.
• Bleeding in the oesophagus represents another serious complication. Though typically gradual, bleeding can occasionally become sudden and severe. This chronic blood loss often leads to iron deficiency  anaemia, causing weakness, fatigue, and further compromising the patient's condition.
• Pain intensifies as the cancer advances, requiring careful management. The pain may manifest behind the breastbone or between the shoulder blades as the tumour invades surrounding tissues or sometimes as upper backache. 
• Futher growth of cancer would involve airway leading to cough or communication between esophagus and trachea. 
• Metastasis (cancer spreading to other organs) frequently occurs with advanced oesophageal cancer. Common sites include:
  • Liver and lungs
  • Distant lymph nodes
  • Bones
  • Peritoneum (abdominal lining)

Oesophageal Cancer Diagnosis

Doctors typically begin with a detailed medical history and physical examination, focusing extra attention on the neck and chest. Afterwards, they recommend specific tests to investigate suspicious findings.

• Imaging tests:
  • Barium swallow: Patients drink a chalky liquid that coats the oesophagus walls, making abnormalities visible on X-rays. Though this used to be the first test in individuals presenting with dysphagia, but it has largely been replaced by more sophisticated and informative  investigations like endoscopy and CT scan. 
  • CT scan: This procedure creates detailed cross-sectional images that show whether cancer has spread to nearby organs, lymph nodes, or distant body parts. This test is required before surgical planning. 
  • MRI scan: Produce detailed soft tissue images and often compliments findings of CT scan. 
  • PET scan: This scan is based on principles of nuclear medicine and uses a radioactive contrast 18 FDG which highlights areas of primary cancer and metastasis and helps in staging the cancer before planning treatment. This is also helpful in assessing response in patients treated by neoadjuvant chemotherapy or chemoradiotherapy. 
• Endoscopy: Upper endoscopy remains the cornerstone of diagnosis. During this technique, the doctor passes a thin, flexible catheter with a camera (endoscope) down the throat while the patient is sedated. Throughout the same procedure, doctors can:
  • Visualize the upper gastrointestinal tract, assess the location of the cancer, document the morphology of the cancer, and possibly the magnitude of obstruction
  • Take tissue samples (biopsies) from suspicious areas
  • Perform endoscopic ultrasound to evaluate how far the cancer has grown into nearby tissues

Oesophagal cancer treatment: Surgical Intervention

Surgery remains the cornerstone of treatment for early-stage oesophageal cancer. Endoscopic resection is an option for small, superficial tumours and is performed using a flexible tube inserted through the throat to remove the cancer. For more advanced tumours, an oesophagectomy is required, which involves removing the affected portion of the oesophagus along with nearby lymph nodes, followed by reconstruction to reconnect the remaining oesophagus to the stomach.

With advances in surgical techniques, minimally invasive approaches such as video-assisted thoracoscopic surgery (VATS) and robotic-assisted surgery are increasingly being used. These methods offer significant benefits including reduced postoperative discomfort, fewer complications, faster recovery, and shorter hospital stays, all without compromising oncological safety.

Multimodality Treatment for Advanced Cancer

In cases of advanced oesophageal cancer, a multimodal approach—combining surgery with chemotherapy and radiation therapy—is often the most effective strategy to improve outcomes and increase the chances of cure.

For cancers located in the lower two-thirds of the oesophagus, treatment typically begins with neoadjuvant therapy (preoperative treatment), most commonly concurrent chemoradiotherapy, followed by surgical resection.

For locally advanced tumours involving the upper third of the oesophagus, definitive chemoradiotherapy is often preferred due to the tumour's proximity to critical airway structures, making surgery more challenging.

Radiation Therapy

Radiotherapy uses high-energy beams to kill cancer cells. The most common method is external beam radiation, which targets the tumour from outside the body. Brachytherapy, which involves placing a radiation source close to the tumour, is less commonly used but can be effective for palliative care, especially in relieving persistent dysphagia (difficulty swallowing).

Chemotherapy

Chemotherapy involves the use of anti-cancer drugs that circulate throughout the body to kill cancer cells. It may be administered before or after surgery, combined with radiotherapy, or used alone in cases where the cancer has spread beyond the oesophagus.

Emerging Treatment Approaches:

• Targeted therapy, which focuses on specific molecular changes in cancer cells.
• Immunotherapy, which stimulates the immune system to recognize and destroy cancer cells.

When to See a Doctor

Seek medical attention promptly if you experience any of the following symptoms:

• Persistent difficulty swallowing (feeling of food sticking or needing extra effort to swallow)
• Unexplained weight loss
• Chest pain or a sensation of pressure
• Worsening heartburn or indigestion
• Chronic cough or hoarseness
• Vomiting or coughing up blood

Prevention

Taking proactive steps can significantly lower the risk of developing oesophageal cancer:

• Avoiding tobacco and excessive alcohol consumption remains the most effective preventive strategy.
• Include protective foods in your diet, such as:
  • Fruits and vegetables, particularly green and yellow varieties
  • Cruciferous vegetables like broccoli, cabbage, and cauliflower
  • High-fibre foods that support overall digestive health
• Maintain a healthy weight through regular exercise and balanced nutrition.
• Effectively manage gastroesophageal reflux disease (GERD) to reduce long-term damage to the oesophagus.
• Individuals diagnosed with Barrett’s oesophagus should undergo routine endoscopic surveillance to detect early cellular changes.

Conclusion

Oesophageal cancer remains a difficult disease due to its tendency to progress silently until later stages. However, advances in medical treatments offer multiple therapeutic options, especially when the disease is caught early. Early detection is key to improving survival rates. Preventive lifestyle choices—particularly avoiding tobacco and limiting alcohol—play a vital role in reducing the risk of this serious condition.

FAQs

1. What are the stages of oesophageal cancer?

Oesophageal cancer staging helps determine how advanced the disease is and guides treatment plans. The staging system ranges from stage 0 (earliest) through stage IV (most advanced).

• Stage 0: Also called high-grade dysplasia, where abnormal cells are found only in the innermost lining
• Stage 1: Cancer has grown into deeper layers but hasn't spread to lymph nodes
• Stage 2: Cancer has grown further into the esophageal wall and may have spread to 1-2 nearby lymph nodes
• Stage 3: Cancer has grown beyond the oesophageal wall or spread to up to 6 nearby lymph nodes
• Stage 4: Cancer has metastasise to distant organs like the liver or lungs

2. What can I expect if I have oesophageal cancer?

Your outlook largely depends on the stage at diagnosis. Early detection significantly improves survival chances.

3. What questions should I ask my doctor?

Firstly, consider asking these essential questions during consultations:

• "What type and stage of oesophageal cancer do I have?"
• "What treatment options are appropriate for my situation?"
• "How will treatment affect my ability to swallow, eat, or speak?"
• "What side effects should I expect from treatment?"
• "What follow-up care will I need after treatment?"

4. Who is at risk of oesophageal cancer?

Several factors increase the possibility of developing esophageal cancer:

• Men (2-4 times more common than in women)
• Those with gastroesophageal reflux disease (GERD)
• People with Barrett's oesophagus
• Smokers and heavy alcohol consumers
• Individuals who are overweight or obese
• Those with a diet low in fruits and vegetables

5. What is the final stage of oesophageal cancer?

Stage 4 is the final stage of oesophageal cancer, wherein cancer has spread beyond the oesophagus to distant organs. 

6. Where is oesophageal cancer pain felt?

Most patients experience discomfort in the centre of their chest, which may worsen during swallowing or when suffering from indigestion. Pain radiates to the back or between the shoulder blades for some individuals, creating a persistent aching sensation. 

7. Can you fully recover from oesophageal cancer?

Complete recovery from oesophageal cancer depends primarily on how early the disease is detected. Patients who get an early diagnosis have a better chance of surviving at least another 5 years compared to people without this disease.

8. Can a blood test detect oesophageal cancer?

Blood tests alone cannot confirm an oesophageal cancer diagnosis. Instead, doctors typically use blood work as part of the broader diagnostic process.