What You

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Cancerof the

Esophagus

NATIONAL INSTITUTES OF HEALTHNational Cancer Institute

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This booklet is about cancer of theesophagus. If you have questions, callthe Cancer Information Service to learnmore about this disease. The staff cantalk with you in English or Spanish.

The phone number is1–800–4–CANCER (1–800–422–6237).The number for deaf and hard of hearingcallers with TTY equipment is1–800–332–8615. The call is free.

Este folleto es acerca del cáncer en elesófago. Si tiene preguntas, llame alServicio de Información sobre el Cáncerpara conocer más acerca de estaenfermedad. Este servicio tiene personalque habla español.

El número a llamar es el1–800–4–CANCER (1–800–422–6237).Personas con dificultades de audicióncon equipo TTY pueden llamar al1–800–332–8615. La llamada es gratis.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health ServiceNational Institutes of Health

Contents

The Esophagus 2

Understanding the Cancer Process 3

Risk Factors 4

Recognizing Symptoms 6

Diagnosing Esophageal Cancer 6

Staging the Disease 7

Treatment 8

Side Effects of Treatment 11

Nutrition for Cancer Patients 13

The Importance of Followup Care 14

Providing Emotional Support 14

National Cancer Institute Information Resources 15

Questions for Your Doctor 17

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What You Need To Know About™Cancer of the Esophagus

he diagnosis of cancer of the esophagus bringswith it many questions and a need for clear,

understandable answers. We hope this National CancerInstitute (NCI) booklet will help. It providesinformation about the symptoms, diagnosis, andtreatment of cancer of the esophagus, and it describessome of the possible causes (risk factors) of thisdisease. Having this important information may make iteasier for patients and their families to handle thechallenges they face.

Cancer researchers continue to study and learn moreabout cancer of the esophagus. The Cancer InformationService (CIS), a free public service of the NCI, canprovide the latest, most accurate information on cancerof the esophagus. The CIS meets the information needsof patients, the public, and health professionals.Specially trained staff provide the latest scientificinformation about cancer in understandable language.They can also provide information about locatingcommunity cancer programs and services. CIS staffanswer questions in English and Spanish and distributeNCI materials, such as the publications mentioned inthis booklet. The toll-free phone number is1–800–4–CANCER (1–800–422–6237). For deaf andhard of hearing callers with TTY equipment, thenumber is 1–800–332–8615.

Many NCI publications are also available on theInternet at the Web sites listed in the “National CancerInstitute Information Resources” section at the end ofthis booklet.

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The Esophagus

he esophagus is a hollow tube that carries foodand liquids from the throat to the stomach. When

a person swallows, the muscular walls of the esophaguscontract to push food down into the stomach. Glands inthe lining of the esophagus produce mucus, whichkeeps the passageway moist and makes swallowingeasier. The esophagus is located just behind the trachea(windpipe). In an adult, the esophagus is about 10inches long.

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Understanding the Cancer Process

ancer is a disease that affects cells, the body’sbasic unit of life. To understand any type of

cancer, it is helpful to know about normal cells andwhat happens when they become cancerous.

The body is made up of many types of cells.Normally, cells grow, divide, and produce more cellswhen they are needed. This process keeps the bodyhealthy and functioning properly. Sometimes, however,cells keep dividing when new cells are not needed. Themass of extra cells forms a growth or tumor. Tumorscan be benign or malignant.

• Benign tumors are not cancer. They usually can beremoved and, in most cases, they do not come back.Cells in benign tumors do not spread to other parts ofthe body. Most important, benign tumors are rarely athreat to life.

• Malignant tumors are cancer. Cells in malignanttumors are abnormal and divide without control ororder. These cancer cells can invade and destroy thetissue around them. Cancer cells can also break awayfrom a malignant tumor and enter the bloodstream orlymphatic system (the tissues and organs thatproduce, store, and carry white blood cells that fightinfection and other diseases). This process, calledmetastasis, is how cancer spreads from the original(primary) tumor to form new (secondary) tumors inother parts of the body.

Cancer that begins in the esophagus (also calledesophageal cancer) is divided into two major types,squamous cell carcinoma and adenocarcinoma,depending on the type of cells that are malignant.Squamous cell carcinomas arise in squamous cellsthat line the esophagus. These cancers usually occur inthe upper and middle part of the esophagus.

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Adenocarcinomas usually develop in the glandulartissue in the lower part of the esophagus. The treatmentis similar for both types of esophageal cancer.

If the cancer spreads outside the esophagus, it oftengoes to the lymph nodes first. (Lymph nodes are small,bean-shaped structures that are part of the body’simmune system.) Esophageal cancer can also spread toalmost any other part of the body, including the liver,lungs, brain, and bones.

Risk Factors

he exact causes of cancer of the esophagus are notknown. However, studies show that any of the

following factors can increase the risk of developingesophageal cancer:

• Age. Esophageal cancer is more likely to occur aspeople get older; most people who developesophageal cancer are over age 60.

• Sex. Cancer of the esophagus is more common inmen than in women.

• Tobacco use. Smoking cigarettes or using smokelesstobacco is one of the major risk factors foresophageal cancer.

• Alcohol use. Chronic and/or heavy use of alcohol isanother major risk factor for esophageal cancer.People who use both alcohol and tobacco have anespecially high risk of esophageal cancer. Scientistsbelieve that these substances increase each other’sharmful effects.

• Barrett’s esophagus. Long-term irritation canincrease the risk of esophageal cancer. Tissues at thebottom of the esophagus can become irritated ifstomach acid frequently “backs up” into the

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esophagus–a problem called gastric reflux. Overtime, cells in the irritated part of the esophagus maychange and begin to resemble the cells that line thestomach. This condition, known as Barrett’sesophagus, is a premalignant condition that maydevelop into adenocarcinoma of the esophagus.

• Other types of irritation. Other causes ofsignificant irritation or damage to the lining of theesophagus, such as swallowing lye or other causticsubstances, can increase the risk of developingesophageal cancer.

• Medical history. Patients who have had other headand neck cancers have an increased chance ofdeveloping a second cancer in the head and neckarea, including esophageal cancer.

Having any of these risk factors increases thelikelihood that a person will develop cancer. Still, mostpeople with one or even several of these factors do notget the disease. And most people who do getesophageal cancer have none of the known risk factors.

Identifying factors that increase a person’s chancesof developing esophageal cancer is the first step towardpreventing the disease. We already know that the bestways to prevent this type of cancer are to quit (or neverstart) smoking cigarettes or using smokeless tobaccoand to drink alcohol only in moderation. Researcherscontinue to study the causes of esophageal cancer andto search for other ways to prevent it. For example,they are exploring the possibility that increasing one’sintake of fruits and vegetables, especially raw ones,may reduce the risk of this disease.

Researchers are also studying ways to reduce therisk of esophageal cancer for people with Barrett’sesophagus.

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Recognizing Symptoms

arly esophageal cancer usually does not causesymptoms. However, as the cancer grows,

symptoms may include:

• Difficult or painful swallowing

• Severe weight loss

• Pain in the throat or back, behind the breastbone orbetween the shoulder blades

• Hoarseness or chronic cough

• Vomiting

• Coughing up blood

These symptoms may be caused by esophagealcancer or by other conditions. It is important to checkwith a doctor.

Diagnosing Esophageal Cancer

o help find the cause of symptoms, the doctorevaluates a person’s medical history and performs

a physical exam. The doctor usually orders a chest x-ray and other diagnostic tests. These tests mayinclude the following:

• A barium swallow (also called an esophagram) is aseries of x-rays of the esophagus. The patient drinksa liquid containing barium, which coats the inside of

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The best ways to prevent cancer of theesophagus are to quit (or never start) usingtobacco and to limit the use of alcohol.

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the esophagus. The barium makes any changes in theshape of the esophagus show up on the x-rays.

• Esophagoscopy (also called endoscopy) is anexamination of the inside of the esophagus using athin lighted tube called an endoscope. An anesthetic(substance that causes loss of feeling or awareness)is usually used during this procedure. If an abnormalarea is found, the doctor can collect cells and tissuethrough the endoscope for examination under amicroscope. This is called a biopsy. A biopsy canshow cancer, tissue changes that may lead to cancer,or other conditions.

Staging the Disease

f the diagnosis is esophageal cancer, the doctorneeds to learn the stage (or extent) of disease.

Staging is a careful attempt to find out whether thecancer has spread and, if so, to what parts of the body.Knowing the stage of the disease helps the doctor plantreatment. Listed below are descriptions of the fourstages of esophageal cancer.

• Stage I. The cancer is found only in the top layers ofcells lining the esophagus.

• Stage II. The cancer involves deeper layers of thelining of the esophagus, or it has spread to nearbylymph nodes. The cancer has not spread to otherparts of the body.

• Stage III. The cancer has invaded more deeply intothe wall of the esophagus or has spread to tissues orlymph nodes near the esophagus. It has not spread toother parts of the body.

• Stage IV. The cancer has spread to other parts of thebody. Esophageal cancer can spread almostanywhere in the body, including the liver, lungs,brain, and bones.

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Some tests used to determine whether the cancer hasspread include:

• CAT (or CT) scan (computed tomography). Acomputer linked to an x-ray machine creates a seriesof detailed pictures of areas inside the body.

• Bone scan. This technique, which creates images ofbones on a computer screen or on film, can showwhether cancer has spread to the bones. A smallamount of radioactive substance is injected into avein; it travels through the bloodstream and collectsin the bones, especially in areas of abnormal bonegrowth. An instrument called a scanner measures theradioactivity levels in these areas.

• Bronchoscopy. The doctor puts a bronchoscope (athin, lighted tube) into the mouth or nose and downthrough the windpipe to look into the breathingpassages.

Treatment

reatment for esophageal cancer depends on anumber of factors, including the size, location,

and extent of the tumor, and the general health of thepatient. Patients are often treated by a team ofspecialists, which may include a gastroenterologist (adoctor who specializes in diagnosing and treatingdisorders of the digestive system), surgeon (a doctorwho specializes in removing or repairing parts of thebody), medical oncologist (a doctor who specializes intreating cancer), and radiation oncologist (a doctor whospecializes in using radiation to treat cancer). Becausecancer treatment may make the mouth sensitive and atrisk for infection, doctors often advise patients withesophageal cancer to see a dentist for a dental exam andtreatment before cancer treatment begins.

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Many different treatments and combinations oftreatments may be used to control the cancer and/or toimprove the patient’s quality of life by reducingsymptoms.

• Surgery is the most common treatment foresophageal cancer. Usually, the surgeon removes thetumor along with all or a portion of the esophagus,nearby lymph nodes, and other tissue in the area.(An operation to remove the esophagus is called anesophagectomy.) The surgeon connects theremaining healthy part of the esophagus to thestomach so the patient is still able to swallow.Sometimes, a plastic tube or part of the intestine isused to make the connection. The surgeon may alsowiden the opening between the stomach and thesmall intestine to allow stomach contents to passmore easily into the small intestine. Sometimessurgery is done after other treatment is finished.

• Radiation therapy, also called radiotherapy,involves the use of high-energy rays to kill cancercells. Radiation therapy affects cells in the treatedarea only. The radiation may come from a machineoutside the body (external radiation) or fromradioactive materials placed in or near the tumor(internal radiation). A plastic tube may be insertedinto the esophagus to keep it open during radiationtherapy. This procedure is called intraluminalintubation and dilation. Radiation therapy may beused alone or combined with chemotherapy asprimary treatment instead of surgery, especially if thesize or location of the tumor would make anoperation difficult. Doctors may also combineradiation therapy with chemotherapy to shrink thetumor before surgery. Even if the tumor cannot beremoved by surgery or destroyed entirely byradiation therapy, radiation therapy can often helprelieve pain and make swallowing easier.

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• Chemotherapy is the use of anticancer drugs to killcancer cells. The anticancer drugs used to treatesophageal cancer travel throughout the body.Anticancer drugs used to treat esophageal cancer areusually given by injection into a vein (IV).Chemotherapy may be combined with radiationtherapy as primary treatment (instead of surgery) orto shrink the tumor before surgery.

• Laser therapy is the use of high-intensity light todestroy tumor cells. Laser therapy affects the cellsonly in the treated area. The doctor may use lasertherapy to destroy cancerous tissue and relieve ablockage in the esophagus when the cancer cannotbe removed by surgery. The relief of a blockage canhelp to reduce symptoms, especially swallowingproblems.

• Photodynamic therapy (PDT), a type of lasertherapy, involves the use of drugs that are absorbedby cancer cells; when exposed to a special light, thedrugs become active and destroy the cancer cells.The doctor may use PDT to relieve symptoms ofesophageal cancer such as difficulty swallowing.

Clinical trials (research studies) to evaluate newways to treat cancer are an important option for manypatients with esophageal cancer. In some studies, allpatients receive the new treatment. In others, doctorscompare different therapies by giving the new treatmentto one group of patients and the usual (standard)therapy to another group. Through research, doctorslearn new, more effective ways to treat cancer. Moreinformation about research studies can be found in theNCI publication Taking Part in Clinical Trials: WhatCancer Patients Need To Know. NCI also has a Website at http://cancertrials.nci.nih.gov that providesgeneral information about clinical trials and detailedinformation about specific ongoing studies. Thisinformation is also available from the Cancer

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Information Service at 1–800–4–CANCER(1–800–422–6237). For deaf and hard of hearing callerswith TTY equipment, the number is 1–800–332–8615.

Side Effects of Treatment

he side effects of cancer treatment depend on thetype of treatment and may be different for each

person. Doctors and nurses can explain the possibleside effects of treatment, and they can suggest ways tohelp relieve symptoms that may occur during and aftertreatment.

• Surgery for esophageal cancer may cause short-termpain and tenderness in the area of the operation, butthis discomfort or pain can be controlled withmedicine. Patients are taught special breathing andcoughing exercises to keep their lungs clear.

• Radiation therapy affects normal as well ascancerous cells. Side effects of radiation therapydepend mainly on the dose and the part of the bodythat is treated. Common side effects of radiationtherapy to the esophagus are a dry, sore mouth andthroat; difficulty swallowing; swelling of the mouth

The NCI’s CancerNet™ Web site providesinformation from numerous NCI sources,including PDQ®, NCI’s cancer informationdatabase. PDQ contains current information oncancer prevention, screening, treatment,supportive care, and ongoing clinical trials.CancerNet also contains CANCERLIT®, adatabase of citations and abstracts on cancertopics from scientific literature. CancerNet can beaccessed at http://cancernet.nci.nih.gov on theInternet.

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and gums; dental cavities; fatigue; skin changes atthe site of treatment; and loss of appetite.

• Chemotherapy, like radiation therapy, affectsnormal as well as cancerous cells. Side effectsdepend largely on the specific drugs and the dose(amount of drug administered). Common side effectsof chemotherapy include nausea and vomiting, poorappetite, hair loss, skin rash and itching, mouth andlip sores, diarrhea, and fatigue. These side effectsgenerally go away gradually during the recoveryperiods between treatments or after treatment is over.

• Laser therapy can cause short-term pain where thetreatment was given, but this discomfort can becontrolled with medicine.

• Photodynamic therapy makes the skin and eyeshighly sensitive to light for 6 weeks or more aftertreatment. Other temporary side effects of PDT mayinclude coughing, trouble swallowing, abdominalpain, and painful breathing or shortness of breath.

Radiation Therapy and You, Chemotherapy and You,and Questions and Answers About Pain Control areuseful NCI booklets that suggest ways for patients tocope with the side effects they experience during andafter cancer treatment.

Doctors and nurses can explain the possibleside effects of treatment, and they can suggestways to help relieve symptoms that may occurduring and after treatment.

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Nutrition for Cancer Patients

ating well during cancer treatment means gettingenough calories and protein to control weight loss

and maintain strength. Eating well often helps peoplewith cancer feel better and have more energy.

However, many people with esophageal cancer findit hard to eat well because they have difficultyswallowing. Patients may not feel like eating if they areuncomfortable or tired. Also, the common side effectsof treatment, such as poor appetite, nausea, vomiting,dry mouth, or mouth sores, can make eating difficult.Foods may taste different.

After surgery, patients may receive nutrients directlyinto a vein. (This way of getting nourishment into thebody is called an IV.) Some may need a feeding tube (aflexible plastic tube that is passed through the nose tothe stomach or through the mouth to the stomach) untilthey are able to eat on their own.

Patients with esophageal cancer are usuallyencouraged to have several small meals and snacksthroughout the day, rather than three large meals. Whenswallowing is difficult, many patients can still managesoft, bland foods moistened with sauces or gravies.Puddings, ice cream, and soups are nourishing and areusually easy to swallow. It may be helpful to use ablender to process solid foods. The doctor, dietitian,nutritionist, or other health care provider can advisepatients about these and other ways to maintain ahealthy diet.

Patients and their families may want to read theNational Cancer Institute booklet Eating Hints forCancer Patients, which contains many usefulsuggestions and recipes.

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The Importance of Followup Care

ollowup care after treatment for esophagealcancer is important to ensure that any changes in

health are found. If the cancer returns or progresses orif a new cancer develops, it can be treated as soon aspossible. Checkups may include physical exams,x-rays, or lab tests. Between scheduled appointments,patients should report any health problems to theirdoctor as soon as they appear.

Providing Emotional Support

iving with a serious disease is challenging. Apartfrom having to cope with the physical and

medical challenges, people with cancer face manyworries, feelings, and concerns that can make lifedifficult. They may find they need help coping with theemotional as well as the practical aspects of theirdisease. In fact, attention to the emotional burden ofhaving cancer is often a part of a patient’s treatmentplan. The support of the health care team (doctors,nurses, social workers), support groups, and patient-to-patient networks can help people feel less isolated anddistressed, and improve the quality of their lives.Cancer support groups provide a setting in whichcancer patients can talk about living with cancer withothers who may be having similar experiences. Patientsmay want to speak to a member of their health careteam about finding a support group. Many also finduseful information in NCI fact sheets and booklets,including Taking Time and Facing Forward.

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National Cancer Institute InformationResources

ou may want more information for yourself, yourfamily, and your doctor. The following National

Cancer Institute (NCI) services are available to helpyou.

TelephoneCancer Information Service (CIS)

Provides accurate, up-to-date information on cancerto patients and their families, health professionals, andthe general public. Information specialists translate thelatest scientific information into understandablelanguage and respond in English, Spanish, or on TTYequipment.

Toll-free: 1–800–4–CANCER (1–800–422–6237)

TTY (for deaf and hard of hearing callers):1–800–332–8615

InternetThese Web sites may be useful:

http://www.nci.nih.gov

NCI’s primary Web site; contains information aboutthe Institute and its programs.

http://cancertrials.nci.nih.gov

cancerTrials™; NCI’s comprehensive clinical trialsinformation center for patients, health professionals,and the public. Includes information on understandingtrials, deciding whether to participate in trials, findingspecific trials, plus research news and other resources.

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http://cancernet.nci.nih.gov

CancerNet™; contains material for healthprofessionals, patients, and the public, includinginformation from PDQ® about cancer treatment,screening, prevention, supportive care, and clinicaltrials; and CANCERLIT®, a bibliographic database,and a glossary of medical terms related to cancer andits treatment.

E-mailCancerMail

Includes NCI information about cancer treatment,screening, prevention, and supportive care. To obtain a contents list, send e-mail tocancermail@icicc.nci.nih.gov with the word “help” inthe body of the message.

FaxCancerFax®

Includes NCI information about cancer treatment,screening, prevention, and supportive care. To obtain acontents list, dial 301–402–5874 from a fax machinehand set and follow the recorded instructions.

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Questions for Your Doctor

his booklet is designed to help you getinformation you need from your doctor so that

you can make informed decisions about your healthcare. In addition, asking your doctor the followingquestions will help you further understand yourcondition. To help you remember what the doctor says,you may take notes or ask whether you may use a taperecorder. Some people also want to have a familymember or friend with them when they talk to thedoctor–to take part in the discussion, to take notes, orjust to listen.

Diagnosis• What tests can diagnose esophageal cancer? Are they

painful?

• How soon after the tests will I learn the results?

Treatment• What treatments are recommended for me?

• What clinical trials are appropriate for my type ofcancer?

• Will I need to be in the hospital to receive mytreatment? For how long?

• How might my normal activities change during mytreatment?

Side Effects• What side effects should I expect? How long will

they last?

• Whom should I call if I am concerned about a sideeffect?

• What will be done if I have pain?

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Followup• After treatment, how often do I need to be checked?

• What type of followup care should I have?

• What type of nutritional support will I need? Wherecan I get it?

• Will I eventually be able to resume my normalactivities?

The Health Care Team• Who will be involved with my treatment and

rehabilitation? What is the role of each member ofthe health care team in my care?

• What has been your experience in caring for patientswith esophageal cancer?

Resources• Are there support groups in the area with people I

can talk to?

• Are there organizations where I can get moreinformation about cancer, specifically esophagealcancer?

• Are there Web sites I can visit that have accurateinformation about cancer, especially esophagealcancer?

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National Cancer Institute (NCI) materials andartwork are in the public domain and not subject tocopyright restrictions when they are produced byGovernment employees. However, most NCI materialsare developed by private-sector writers, designers,photographers, and illustrators under contract to theGovernment. The copyright for these materials oftenremains in the hands of the originators, and it isnecessary to request permission to use or reproducethese materials. In many cases, permission will begranted, although a credit line and/or fees for usagemay be required. To obtain permission, write toPermissions Department, National Cancer Institute,Room 10A28, 31 Center Drive, MSC 2580, Bethesda,MD 20892-2580.

The National Cancer Act, passed by Congress in1971, made research a national priority. Since thattime, the National Cancer Institute (NCI), the leadFederal agency for cancer research, has collaboratedwith top researchers and facilities across the country toconduct innovative research leading to progress incancer prevention, detection, diagnosis, and treatment.These efforts have resulted in a decrease in the overallcancer death rate, and have helped improve and extendthe lives of millions of Americans.

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NIH Publication No. 00–1557Revised October 1999Printed January 2000

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