What follows is from Incidence of Esophageal Cancer in the United States from 2001-2015: A United [Cancer Statistics Analysis of 50 States [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Cureus. 2018 Dec; 10(12): e3709.
Esophageal cancer is the seventh leading cause of death in males in the United States (US) . There were approximately 17,290 new cases of esophageal cancer and 15,850 deaths from esophageal cancer in 2018 . The incidence varies based on a variety of risk factors and location within the US and other Western countries [2, 3]. Squamous cell carcinoma is the most common histology for esophageal cancer worldwide; however, in the US, adenocarcinoma is the most predominant histology .
Prior studies have shown that the incidence of esophageal adenocarcinoma is increasing and the incidence of esophageal squamous cell carcinoma is decreasing .
Important risk factors for esophageal adenocarcinoma include male sex, white race, gastroesophageal reflux disease, Barrett’s esophagus, obesity, tobacco, alcohol intake, and a diet low in fruits and vegetables .
Protective medications for esophageal adenocarcinoma include non-steroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitor (PPIs) and statins in those with Barrett’s esophagus .
Risk factors for esophageal squamous cell carcinoma include black race, female sex in white individuals, smoking, alcohol, diets such as tea and coffee .
In our study, there was an overall 4.41:1 male to female incidence ratio. Incidence in females was decreasing the entire time from 2001 to 2015, whereas in males the incidence was initially increasing; however, after 2006 the incidence started to decrease at a rate greater than that in females. The overall incidence of EAC, when stratified by race, showed that blacks had the greatest overall incidence but that the incidence was also decreasing at the fastest rate. As above, an important risk factor for the development of ESCC is smoking. Over the years, blacks have had the steepest decline in smoking rates [10, 11]. Thus, our findings can possibly be explained by the decreasing incidence of ESCC due to declining smoking prevalence [10, 11].
In our study evaluating the incidence of esophageal cancer in all 50 states, we found that the overall incidence is greatest in males, blacks, distant disease, EAC, and those in the Midwest with EAC. We also found that for race, black individuals have the fastest decline in incidence and that for the stage at diagnosis, regional disease is on the rise. Moreover, although the overall incidence of EAC has started to decline in the US, there is still a significant overall incidence of EAC in the Midwest and a rising incidence in the Northeast, which may be related to higher rates of obesity in these areas. Our study is the first to evaluate esophageal cancer incidence in all 50 states and provides important trends and risk factors for the development of this cancer. Ultimately, we will need to use this data to improve surveillance guidelines for at-risk populations.
Esophageal cancer is a disease in epidemiologic transition. Until the 1970s, the most common type of esophageal cancer in the United States was squamous cell carcinoma, which has smoking and alcohol consumption as risk factors. Since then, there has been a steep increase in the incidence of esophageal adenocarcinoma, for which the most common predisposing factor is gastroesophageal reflux disease (GERD). See the image below.
Cascade of events that lead from gastroesophageal reflux disease to adenocarcinoma.
Signs and symptoms
Presenting signs and symptoms of esophageal cancer include the following:
Dysphagia (most common); initially for solids, eventually progressing to include liquids (usually occurs when esophageal lumen < 13 mm)
Weight loss (second most common) due to dysphagia and tumor-related anorexia.
Bleeding (leading to iron deficiency anemia)
Epigastric or retrosternal pain
Bone pain with metastatic disease
Hoarseness (due to the involvement of the recurrent laryngeal nerve)
- Intractable coughing or frequent pneumonia (due to tracheobronchial fistulas caused by direct invasion of tumor through the esophageal wall and into the mainstem bronchus)
Physical findings include the following:
Typically, normal examination results unless the cancer has metastasized
Hepatomegaly (from hepatic metastases)
Lymphadenopathy in the laterocervical or supraclavicular areas (reflecting metastasis)
See Presentation for more detail.
Laboratory studies such as complete blood count (CBC) and comprehensive metabolic panel (CMP) focus principally on patient factors that may affect treatment (eg, nutritional status, renal function).
Imaging studies used for diagnosis and staging include the following:
Esophagogastroduodenoscopy (EGD; allows direct visualization and biopsies of the tumor)
Endoscopic ultrasonography (EUS; most sensitive test for T and N staging ; used when no evidence of M1 disease)
Computed tomography (CT) of the abdomen and chest with contrast (for assessing lung and liver metastasis and invasion of adjacent structures)
Pelvic CT scan with contrast if clinically indicated
Positron emission tomography (PET) scanning (for staging)
Bronchoscopy (if tumor is at or above the carina, to help exclude invasion of the trachea or bronchi)
Laparoscopy and thoracoscopy (for staging regional nodes)
Barium swallow (very sensitive for detecting strictures and intraluminal masses, but now rarely used)
For staging information, see Esophageal Cancer Staging.
See Workup for more detail.
[See Esophageal Carcinoma Imaging for more information]