Oesophageal cancer

Last reviewed: 30 Dec 2022

Last updated: 23 Nov 2022

Oesophageal cancer incidence is increasing across the developed world. Men are considerably more likely than women to develop the disease.

The two main histological types are squamous cell carcinoma and adenocarcinoma. In the developed world, adenocarcinomas predominate.

Low socioeconomic status, smoking, excessive alcohol use, GORD, Barrett's oesophagus, and obesity are some of the main risk factors.

Tumours are often locally advanced at the time of diagnosis. Accurate staging is important for prognosis and treatment planning.

Superficial intramucosal oesophageal cancer is best managed by endoscopic resection and surveillance. Early-stage cancers in surgical candidates are best treated by oesophagectomy.

For locally advanced disease, combined modality therapy is considered the current standard. This involves chemotherapy or chemoradiotherapy followed by surgery.

Targeted therapies can be used in patients with metastatic oesophageal and oesophageal junction cancer.

Treatment decisions for patients with recurrent or refractory disease are informed by prior treatment history.

Definition

Most oesophageal cancers are neoplastic mucosal lesions that originate in the epithelial cells lining the oesophagus.

Oesophageal cancers are usually squamous cell carcinomas or adenocarcinomas.

Rarely, other cancers, such as melanoma, sarcoma, small cell carcinoma, or lymphoma, can occur in the oesophagus.

History and exam

Key diagnostic factors

presence of risk factors
dysphagia
odynophagia
weight loss

More key diagnostic factors

Other diagnostic factors

hoarseness
hiccups
postprandial/paroxysmal cough

Other diagnostic factors

Risk factors

male sex
older age
tobacco use
excessive alcohol use (squamous cell carcinoma)
Barrett's oesophagus (adenocarcinoma)
GORD (adenocarcinoma)
hiatus hernia (adenocarcinoma)
family history of oesophageal or other cancer (squamous cell carcinoma)
low socioeconomic status
non-white race (squamous cell carcinoma)
high-temperature beverages and foods (squamous cell carcinoma)
drinking maté (squamous cell carcinoma)
low intake of fresh fruit and vegetables
obesity (adenocarcinoma)
human papillomavirus (squamous cell carcinoma)
achalasia
vitamin and mineral deficiencies (squamous cell carcinoma)
poor oral hygiene (squamous cell carcinoma)

More risk factors

Diagnostic investigations

1st investigations to order

oesophagogastroduodenoscopy (OGD) with biopsy
CT thorax and abdomen
FDG-PET scan

More 1st investigations to order

Investigations to consider

comprehensive metabolic profile
MRI thorax and abdomen
endoscopic ultrasound (EUS) ± fine needle aspiration (FNA)
bronchoscopy ± FNA
thoracoscopy and laparoscopy
pulmonary function tests
cardiac stress test
echocardiogram

More investigations to consider

Treatment algorithm

ACUTE

limited disease (cT1, cN0, M0)

localised disease (cT2, cN0, M0): suitable for surgery

localised disease (cT2, cN0, M0): unsuitable for surgery

locally advanced disease (cT3-4, cN1-3, M0): suitable for surgery

locally advanced disease (cT3-4, cN1-3, M0): unsuitable for surgery

metastatic (M1) disease

ONGOING

recurrent disease

Contributors

Authors

Naureen Starling, BSc(Hons), MBBS, MD(Res), FRCP

Consultant Medical Oncologist in GI Cancers

Associate Director of Clinical Research, GI and Lymphoma

The Royal Marsden Hospital NHS Trust

London

Disclosures

NS has received research funding from AstraZeneca, BMS, and Pfizer; travel and accommodation funding from AstraZeneca, BMS, Eli Lilly, Merck, Roche, and MSD Oncology; honoraria from Eli Lilly, Merck Serono, MSD Oncology, Pierre Fabre, Servier, GSK, and Amgen. She has been on the advisory board for Pfizer, AstraZeneca, Servier, and MSD (Merck). NS is an Honorary Clinical Senior Lecturer within the Division of Clinical Studies at the Institute of Cancer Research and serves on the UK National Cancer Research Institute (NCRI) oesophago-gastric sub-group. NS has acted as a clinical expert in oesophago-gastric cancer for NICE (guideline committee and technology appraisal) and is an upper GI expert for International Cancer Benchmarking Partnership. She is a Trustee for Pancreatic Cancer UK and a member of the EORTC General Assembly representing The Royal Marsden, as well as a member of the European Society for Medical Oncology (ESMO) Gastrointestinal Faculty. Educational roles include the NIHR Training Lead for NIHR Biomedical Research Centre, member of the Cancer Research Centre of Excellence training committee, Deputy Training Programme Director (one of three) for South London Medical Oncology Training, member of the pan-London specialist Medical oncology training committee, and member of the Medical Oncology National Recruitment steering committee.

Caroline Fong, MBChB, MRes, MRCP

Clinical Research Fellow

GI and Lymphoma Unit

The Royal Marsden Hospital NHS Trust

London

Disclosures

CF declares that she has no competing interests.

Acknowledgements

Dr Naureen Starling and Dr Caroline Fong would like to gratefully acknowledge Dr Mark J. Krasna and Dr Ghulam Abbas, previous contributors to this topic.

Disclosures

MJK is an author of several references cited in this topic. GA declares that he has no competing interests.

Peer reviewers

Peter McCulloch, MBChB, MA, MD, FRCS (Ed), FRCS (Glas)

Clinical Reader in Surgery

Nuffield Department of Surgery

University of Oxford

Oxford

Disclosures

PM declares that he has no competing interests.

Nikhil I. Khushalani, MD

Assistant Professor of Oncology

Roswell Park Cancer Institute

Buffalo

Disclosures

NIK has received funding for the conduction of clinical trials and associated translational studies from Merck, Pfizer, and Astra-Zeneca. NIK has a grant from the National Comprehensive Cancer Network (from research support by Roche).

Differentials
- Benign stricture
- Achalasia
- Barrett's oesophagus
More Differentials
Guidelines
- ACR appropriateness criteria: staging and follow-up of oesophageal cancer
- NCCN clinical practice guidelines in oncology: esophageal and esophagogastric junction cancers
More Guidelines
Patient leaflets
Oesophageal cancer
Stopping smoking
More Patient leaflets
Log in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer

Oesophageal cancer

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

limited disease (cT1, cN0, M0)

localised disease (cT2, cN0, M0): suitable for surgery

localised disease (cT2, cN0, M0): unsuitable for surgery

locally advanced disease (cT3-4, cN1-3, M0): suitable for surgery

locally advanced disease (cT3-4, cN1-3, M0): unsuitable for surgery

metastatic (M1) disease

recurrent disease

Contributors

Authors

Naureen Starling, BSc(Hons), MBBS, MD(Res), FRCP

Disclosures

Caroline Fong, MBChB, MRes, MRCP

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Peter McCulloch, MBChB, MA, MD, FRCS (Ed), FRCS (Glas)

Disclosures

Nikhil I. Khushalani, MD

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice