Oesophageal cancer

The oesophagus is a muscular tube about twenty-five centimetres long that runs from the throat down to the stomach; the throat itself is a different organ, and the tumours that grow there are different ones. The inside of the oesophagus is wide and stretchy, so a tumour can grow for a long time without giving itself away, and the first complaint rarely comes at the beginning of the illness. Hence the rule that makes the rest of this page worth reading: new difficulty in swallowing in an adult is a reason to have a gastroscopy, not a reason to wait and see whether it settles.

How it announces itself

The main sign is dysphagia — the feeling that food is not going down freely. With a tumour it advances in steps. At first only firm food sticks: a piece of meat, dry bread, rice, and you find yourself chewing harder and washing it down. Weeks or months later soft food behaves the same way, then purée and porridge, and in advanced cases water and even saliva will not pass and have to be spat out. That steady narrowing of what you can still swallow is what tells a tumour apart from a spasm or a nervous lump in the throat, which come and go and stay unchanged for years.

Other complaints usually travel with the swallowing trouble:

• pain or a feeling of pressure behind the breastbone at the moment of swallowing;
• bringing up undigested food soon after a meal, sometimes at night onto the pillow;
• heartburn that has changed character: more often, more severe, or no longer answering the medicines that used to work;
• hoarseness without a cold that lasts more than three weeks;
• a cough that will not clear, particularly one that starts while you are drinking;
• weight loss without dieting, loss of appetite, constant tiredness;
• black tarry stools or vomiting blood — uncommon, but a sign of bleeding from the tumour.

Two of these deserve explaining. Hoarseness here is not the tail end of a cold: a tumour or enlarged lymph nodes can catch the nerve that controls a vocal cord. And choking specifically on liquids means that the contents of the oesophagus are getting into the airway, which cannot wait.

What else swallows just as badly

Dysphagia on its own does not mean cancer. Several conditions look exactly the same, are treated quite differently, and cannot be told apart from the story alone:

• a scarred narrowing after years of reflux — acid damages the lower oesophagus and a firm ring forms where the ulcers healed;
• achalasia — the muscular ring at the entrance to the stomach stops relaxing. It stands out because solids and liquids stick equally badly from the very start, and at night the contents of the oesophagus come back up;
• eosinophilic oesophagitis, an allergic inflammation, commoner in young men with asthma or hay fever; the classic episode is a piece of meat wedged fast and needing an endoscopy;
• a thin ring or web low in the oesophagus: nothing for years, then a sudden episode with poorly chewed food;
• neurological illness — stroke, parkinsonism, myasthenia. Here the person chokes at the very start of the swallow, coughs, and food comes back through the nose;
• pressure from outside — an enlarged thyroid, a lung tumour, or lymph nodes in the chest;
• a lump in the throat without any real swallowing problem: the lump is felt all the time, yet food goes down normally and weight stays steady.

These possibilities are separated not by the conversation in the consulting room but by endoscopy, and sometimes by a study of pressures inside the oesophagus. So the person who is sure it is "just nerves" needs looking into as well.

Two diseases under one name

The words "oesophageal cancer" cover two different tumours with different causes.

Squamous cell carcinoma grows from the lining of the upper and middle third. It is linked to smoking, spirits, the habit of drinking scalding tea or maté, and a diet short on vegetables. A few rare causes are worth naming out loud, because they are seldom considered: scarring after swallowing a caustic liquid in childhood, long-standing untreated achalasia, radiotherapy to the chest in the past, and a very rare inherited condition that thickens the skin of the palms and soles, in which the risk is exceptionally high and the family needs monitoring.

Adenocarcinoma grows in the lower third, next to the stomach, and its story is a different one: years of acid coming up, excess weight, smoking. Over recent decades it has become commoner than the squamous form wherever obesity is widespread.

What both forms share is age and sex: the disease is rare below forty-five, most cases appear over sixty, and it is several times commoner in men. But "rare" is not "never" — being young does not excuse leaving someone unexamined who has stopped swallowing normally.

Barrett's oesophagus, and what lowers the risk

Barrett's oesophagus is the remodelling of the lining of the lower oesophagus under years of acid: the cells come to resemble those of the bowel. It does not hurt and causes no symptoms of its own, and it is found by chance during a gastroscopy done for heartburn. For any one person the chance of it turning into a tumour is small, but it is the only stage at which the disease can be intercepted before it starts. That is why confirmed Barrett's is followed with repeat gastroscopies to a schedule, and as soon as altered cells appear the area is removed endoscopically, without coming to surgery. If you were once given this diagnosis and the follow-up then lapsed, it is worth restarting.

What genuinely shifts the risk: stopping smoking, cutting down alcohol, losing excess weight, treating long-standing heartburn rather than putting up with it for years, letting very hot drinks cool, and keeping vegetables and fruit on the table daily. None of it is a guarantee, but every item moves the odds the right way.

How the diagnosis is made

The diagnosis is made by gastroscopy with biopsy, and by nothing else. A thin flexible tube with a camera is passed through the mouth, the lining is inspected and small pieces of tissue are taken; a pathologist studies them under the microscope, and only that report separates a tumour from a scar or from inflammation. The test takes about a quarter of an hour, the throat is numbed with a spray, and sedation — medicine that leaves you drowsy and remembering little — is added by choice or where indicated.

This deserves its own paragraph, because it is where time is most often lost. A normal blood test does not rule out oesophageal cancer. There may be no anaemia, and no blood test exists that picks this tumour up. An abdominal ultrasound scan barely sees the oesophagus at all — it is looking at other organs. A barium swallow will show a narrowing and its shape, but it cannot say whether that is scar or tumour and it yields no cells. And the commonest trap of all: medicines that suppress acid production relieve heartburn when there is a tumour too. Feeling better is neither a test nor a reassurance. If the swallowing complaint persists, someone has to look inside.

What is worked out once it is confirmed

Once the tumour is confirmed, the next task is to measure how far it has spread, because that governs the choice between surgery, radiotherapy and drug treatment. The usual tests are a CT scan of chest and abdomen, an endoscopic ultrasound (the probe sits on the tip of the endoscope and shows how deeply the tumour has grown into the wall and whether nearby lymph nodes are involved) and, where needed, a PET-CT scan to look for distant deposits. For tumours of the lower third a short look inside the abdomen through small cuts is sometimes added, so that tiny deposits on the lining of the abdomen, which scans miss, are not overlooked.

Alongside this the person is assessed too: weight and how it is moving, nutritional state, heart and lungs — surgery on the oesophagus is demanding and you need to come to it in condition. The tissue is also checked for several molecular markers; whether targeted medicines and immunotherapy will work depends on them. The results are not read by one doctor but by a team meeting of surgeon, oncologist, radiotherapist and endoscopist, and that is where the treatment plan is built.

How it is treated

Very early tumours that have not passed beyond the surface layer are removed during the endoscopy itself, without any cutting. This is not often possible and is nearly always a find from Barrett's surveillance.

Where the tumour is confined to the oesophagus and nearby lymph nodes, surgery remains the backbone: the affected stretch is removed along with the nodes and the stomach, or less often a length of bowel, is brought up in its place. Surgery on its own is now uncommon — a course of chemotherapy or chemoradiotherapy is given beforehand to shrink the tumour, and drug treatment is sometimes added afterwards. For squamous cancer of the upper third surgery is technically hard, and chemoradiotherapy is often chosen instead as the definitive treatment; the results are no worse.

If the tumour has gone beyond what can be removed, or has thrown off distant deposits, the aim changes: to hold the disease back and give the person back the ability to eat and to live without pain. Chemotherapy, immunotherapy and targeted medicines do that work, while the passage itself is restored by stretching the narrowed segment or fitting a stent, a small mesh tube that props the channel open. Feeding is not a side issue: a dietitian should be involved, and where swallowing becomes impossible a feeding tube is placed. The palliative care team joins not "at the end" but as soon as symptoms start to weigh, and early involvement improves both comfort and how the main treatment is tolerated.

When help is needed urgently

Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine, 112) if any of these appear:

• vomiting blood or material that looks like coffee grounds, or black tarry stools;
• sudden weakness, dizziness, pallor and cold sweat — signs of blood loss;
• complete blockage: not even water passes and saliva has to be spat out;
• choking, going blue, or a coughing fit on trying to swallow liquid;
• severe chest pain with breathlessness and fever after a gastroscopy, a dilatation or a stent — that is how a tear in the wall of the oesophagus shows itself.

See a doctor the same day, without an ambulance, if a piece of food has been stuck for several hours; if pain on swallowing has sharply worsened; or if fever and a productive cough appear in someone who has been choking on food for a while, since that may be pneumonia from food entering the lungs.

Online consultation

An online appointment is useful at two points. The first is when the swallowing trouble has just started and it is unclear what to do with it. The doctor will unpick how it is built — what sticks and for how long, whether it has been changing, what the weight is doing — and will say plainly whether a gastroscopy is needed and how urgently; that saves months of treating heartburn on your own. The second is once the diagnosis is made: the doctor will put the reports and the stage into plain language, explain what each test is for, help you prepare questions for the team meeting, and work through eating and side effects between hospital visits.

What an online appointment cannot replace: examination, gastroscopy and biopsy — without them there is no diagnosis and cannot be one. And with the signs from the previous section the person to contact is not a doctor in a chat window but the ambulance service.

This material is for information only and does not replace medical advice.