Oesophageal Cancer Diagnosis and Treatment

Oesophageal cancer is diagnosed by endoscopy and biopsy, staged with PET-CT or contrast CT and, in early disease, endoscopic ultrasound, and then treated according to three variables: the stage, the histology (squamous cell carcinoma or adenocarcinoma) and the patient's fitness. Very early tumours can be removed endoscopically. Locally advanced tumours need multimodality treatment that combines chemotherapy, radiotherapy and surgery.

Dr. Preeti Vijayakumaran, Consultant, Oncology, Artemis Hospitals, Gurugram, India, trained at Tata Memorial Hospital, Mumbai, where she completed a fellowship in thoracic surgery and treated oesophageal cancer as part of everyday thoracic practice. She chose the disease for her Jivo Masterclass for international doctors because it is a heavy burden and a major challenge in both regions, and because the hardest patients to treat are the ones who present with locally advanced disease. This guide covers the burden, the warning signs, how treatment is chosen, risk factors and prevention, and follow-up after treatment. Three companion articles go deeper into staging and the diagnostic workup, endoscopic treatment of early oesophageal cancer and the trial evidence and surgery for locally advanced disease.

The global burden of oesophageal cancer

The GLOBOCAN cancer statistics rank oesophageal cancer as the 11th most common cancer by incidence and the 7th most common cause of cancer death. The higher rank for mortality than for incidence reflects how often the disease proves fatal.

Asia carries the largest absolute burden of incidence, prevalence and mortality, followed by Europe, Africa and North America. Incidence is highest in Eastern Asia, followed closely by Eastern Africa and Southern Africa, with other Southeast Asian countries also affected. Men are affected significantly more often than women.

Why men are more affected remains unexplained. Asked in the discussion whether a genetic factor accounts for the difference, Dr. Vijayakumaran said there is no established genetic risk factor; much of the excess is attributed to other risk factors such as smoking and dietary habits.

Why most patients present late

The central problem in Dr. Vijayakumaran's setting is timing. Early oesophageal cancer causes subtle symptoms, and patients tend to ignore them until the tumour is well established. In Dr. Vijayakumaran's experience, most present at stage II or stage III, and many at stage IV.

Countries with stringent endoscopic screening programmes detect early dysplastic changes (abnormal but not yet invasive cells) and early cancers, and that is where most genuinely early-stage oesophageal cancer is found. Without screening, the disease is usually recognised only once swallowing has become difficult.

Her advice to junior doctors follows from this. The ignorance about the disease in the community is the first obstacle: early difficulty in swallowing is often dismissed as a symptom of some other common ailment. Doctors should explain to patients why an early medical evaluation matters, because early endoscopy and early detection make a large difference to outcome, and should take an active part in educating the public about the disease, its diagnosis and the treatments available. Detected early, the disease offers the widest range of curative options.

Early warning signs and symptoms of oesophageal cancer

Early disease often causes no symptoms at all. When it does, the typical complaint is slight discomfort or difficulty when swallowing that gradually worsens, mainly with solid food and less with liquids.

More advanced disease produces the classical picture:

• Dysphagia (difficulty swallowing), which may not be painful.
• Unintentional, progressive weight loss. Dr. Vijayakumaran treats a loss of about 10% of body weight in less than three months as significant.
• Heartburn-like symptoms, regurgitation and a sensation of food getting stuck.
• Vomiting, and sometimes vomiting of blood (haematemesis), with more aggressive or more obstructive tumours.
• Cough and hoarseness of voice once the tumour invades nearby structures.

Any patient with progressive difficulty in swallowing should have an endoscopy. The full diagnostic and staging pathway, including when PET-CT, endoscopic ultrasound, bronchoscopy and laparoscopy are used, is set out in the article on how oesophageal cancer is diagnosed and staged.

How oesophageal cancer treatment is chosen: stage, histology and fitness

Three parameters decide the plan.

1. Stage. Early disease is clinically T1a or T1b with no node involvement (N0). Intermediate disease is clinically T2 N0. Anything beyond that is locally advanced or advanced.
2. Histology. Squamous cell carcinoma and adenocarcinoma have different preferred treatment regimens.
3. The patient's condition. Dr. Vijayakumaran considers this the most important of the three. Oesophageal cancer is a disease of older people: patients are usually over 50 or 60, sometimes over 70, and many have several other illnesses. Matching treatment to what the patient can tolerate is often the hardest part of the decision.

Once the cancer is diagnosed and staged, the first question is whether it can be treated endoscopically, needs surgery, or needs multimodality treatment. Very early disease can be treated endoscopically. Intermediate and advanced disease receives multimodality treatment individualised to the patient. Patient preference and fitness are of the utmost importance at every step.

Wherever possible, the decision should be made at a multidisciplinary tumour board, with the surgical oncologist, medical oncologist, radiation oncologist, nuclear medicine specialist and radiologist reviewing the stage and the options together.

Oesophageal cancer treatment options at a glance

The modalities available for oesophageal cancer are:

• Local endoscopic therapy: ablation, or endoscopic resection by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD).
• Surgery: oesophagectomy, the removal of the oesophagus with reconstruction, usually using the stomach.
• Systemic therapy: chemotherapy, immunotherapy and targeted therapy.
• [Radiotherapy](/treatment-cost/radiation-therapy-radiotherapy): external beam radiotherapy (EBRT) or brachytherapy (radiation delivered from a source placed inside the oesophagus).
• Supportive care: nutritional rehabilitation and chest physiotherapy, which Dr. Vijayakumaran describes as essential components of management.

In outline, her approach is as follows. For early disease (clinically T1a N0 M0), the choice is between endoscopic ablation and endoscopic resection. For locally advanced squamous cell carcinoma, neoadjuvant chemoradiation (chemotherapy and radiotherapy before surgery) is given to patients who will go on to surgery, and definitive chemoradiation to those whose disease is unresectable. For locally advanced adenocarcinoma, the standard is perioperative chemotherapy (before and after surgery), with neoadjuvant chemoradiation followed by surgery as an alternative in some cases. More recent trials have refined both pathways; the evidence is reviewed in the article on locally advanced oesophageal cancer and the major trials.

For widespread metastatic disease, chemotherapy combined with immunotherapy or targeted therapy offers a modest survival gain and a clearer benefit in quality of life, as discussed in the same article.

Oesophageal cancer risk factors and prevention

Prevention starts with the risk factors, which differ by histological subtype.

Adenocarcinoma is linked to obesity and to longstanding gastro-oesophageal reflux disease (GORD), with smoking adding to the risk. Prevention therefore means stopping smoking, controlling weight, treating reflux disease medically so that the underlying problem is corrected, and, in patients who already have a predisposing condition such as Barrett's oesophagus (a change in the lining of the lower oesophagus caused by chronic reflux), starting endoscopic surveillance early and monitoring it stringently.

Squamous cell carcinoma is related to smoking, alcohol and dietary habits, including very hot drinks, and changing those habits can make a difference.

Caustic injury is a further, important predisposing condition. A doctor in the session described frequent cases of corrosive ingestion in suicide attempts. Dr. Vijayakumaran sees many such cases in her own practice as well. The chronic oesophagitis that follows can progress to stricture (scarring and narrowing) and predisposes to oesophageal cancer, so survivors of caustic injury need a strict surveillance protocol. In practice, most go on to develop strictures that cause severe dysphagia and a chronic inability to eat; these patients are offered oesophagectomy with reconstruction of a new oesophagus. Those who do not develop stricturing disease should have endoscopy every six months, with biopsy of any suspicious area. Further imaging is not required unless a biopsy proves disease.

Screening for oesophageal cancer: when to start

Practice varies between institutions and guidelines. In Dr. Vijayakumaran's setting, screening is recommended from the age of 35 to 40 years for patients with reflux symptoms or a risk of Barrett's oesophagus. How screening findings are acted on, from surveillance of non-dysplastic Barrett's oesophagus to ablation or resection of high-grade dysplasia, is described in the article on early oesophageal cancer and endoscopic treatment.

Follow-up and surveillance after oesophageal cancer treatment

The follow-up schedule depends on the stage at presentation and the treatment given.

After treatment for T1 N0 disease, patients are followed with endoscopic surveillance:

• every 3 months in the first year
• every 6 months in the second year
• annually thereafter

Imaging may not be needed for T1a disease but may be recommended for T1b disease.

After treatment for locally advanced disease (whether definitive chemoradiation or preoperative treatment followed by surgery), follow-up relies on imaging, usually a contrast-enhanced CT of the thorax, abdomen and pelvis or a PET scan. Scans are done every six months for the first two years and annually thereafter, up to five years.

After definitive chemoradiation, where the oesophagus has not been removed, patients also need endoscopic surveillance. If disease recurs, salvage surgery should be offered to those who can tolerate it.

Questions the field has yet to answer

Dr. Vijayakumaran closed with two open questions.

Neoadjuvant immunotherapy. Immunotherapy has established a significant role in lung cancer and an adjuvant role (after surgery) in oesophageal cancer. Whether adding it before surgery improves outcomes and survival is, in her view, a question likely to be answered in the near future. For gastro-oesophageal junction adenocarcinoma, perioperative durvalumab with FLOT chemotherapy was approved in 2025 after the MATTERHORN trial; for other oesophageal cancers, immunotherapy before surgery remains investigational.

Organ preservation. If definitive chemoradiation could match the survival of treatment that includes surgery, many patients could avoid oesophagectomy and the lifelong changes that follow it. The obstacle is that there is no reliable way to prove a complete pathological response (no viable tumour left) without removing the oesophagus: PET scans and endoscopic surveillance cannot yet distinguish a complete response from residual disease with certainty. Stricter surveillance protocols after neoadjuvant treatment may, in the years ahead, allow more patients to keep their oesophagus.

The questions doctors asked during the session, on topics from cryotherapy to screening age, are collected in the Live Discussion from this masterclass.