Screening, Prevention and Risk Factors for Esophageal Cancer

Prevention and screening for esophageal cancer both start from the same point: understanding that adenocarcinoma and squamous cell carcinoma are driven by genuinely different risk factors, even though they end up looking similar by the time a patient presents.

Two Subtypes, Two Sets of Risk Factors

For adenocarcinoma, the main drivers are obesity, chronic reflux disease, and smoking and alcohol use, so limiting smoking and alcohol, and medically managing an existing gastroesophageal reflux disease rather than leaving it untreated, genuinely reduces risk. For squamous cell carcinoma, the pathology relates more to smoking and to diet habits, and regulating both can make a real difference. Notably, there is no established genetic risk factor that explains why the disease is significantly more common in men than in women, despite this being a consistent finding worldwide; the working explanation leans on these behavioural and dietary risk factors rather than genetics.

When to Start Screening

In practice, screening by endoscopy is recommended starting at age 35 to 40, particularly for patients with reflux symptoms or a risk of Barrett's esophagus, though the exact age varies by institutional protocol and guideline. Patients who already have an existing predisposing condition should be started on more stringent endoscopic surveillance earlier rather than later.

What Endoscopic Mapping and Surveillance Look Like

For patients under surveillance, any area on endoscopic mapping that shows dysplastic change is biopsied. If repeated biopsies show no dysplasia, the patient stays on routine surveillance. Low-grade dysplasia is followed up rather than treated immediately. High-grade dysplasia in a flat lesion under 2 cm is ablated, while high-grade dysplasia over 2 cm, or with a nodular appearance, is taken for endoscopic resection with histopathology follow-up on the specimen.

Caustic Injury: An Under-Recognised Precancerous Pathway

One risk pathway that doesn't fit neatly into either subtype's usual list is caustic esophageal injury, seen in practice from cases of chemical poisoning in suicide attempts. This injury can cause chronic esophagitis, which over time can progress to stricturous disease and become a genuine predisposing cause of esophageal cancer. Any patient who survives such an injury and goes on to develop stricturous disease should be placed on a very stringent surveillance protocol going forward, precisely because that chronic esophagitis functions as a real precancerous condition rather than a benign, self-limiting injury. Preventively, patients who develop extensive stricturous disease with significant dysphagia and an inability to sustain oral nutrition are offered an esophagectomy with a neo-esophagus, while those who do not develop stricture are managed with six-monthly endoscopic evaluation and biopsy of any suspicious area instead, with further imaging reserved for a biopsy-proven finding.

This article is based on a Jivo Masterclass session conducted by Dr. Preeti Vijayakumaran, Consultant, Surgical Oncology, Artemis Hospital, Gurugram. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording