01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Oesophageal cancer most often presents through progressive dysphagia, weight loss, regurgitation or odynophagia, but iron-deficiency anaemia, aspiration and persistent chest or epigastric discomfort may be the first clue. Adenocarcinoma commonly arises in the distal oesophagus or junction in association with Barrett's oesophagus, reflux, obesity and smoking. Squamous-cell carcinoma can occur throughout the oesophagus and is associated with tobacco, alcohol and other mucosal exposures. Risk factors change probability; they do not replace symptom-led referral.
The suspected-cancer pathway is a route to timely definitive investigation, not a diagnosis. Endoscopy should document tumour level, length, circumference, luminal patency and junctional involvement and obtain adequate tissue. Once malignancy is confirmed, CT assesses distant and local anatomy. PET-CT can disclose occult metastases in potentially curable oesophageal or junctional disease; EUS refines local wall and nodal staging when traversable and when the result will alter management. Staging laparoscopy is selective rather than automatic for oesophageal disease.
Treatment decisions depend on stage, histology, tumour site, performance status, frailty, cardiopulmonary reserve and the patient's priorities. The MDT may offer endoscopic mucosal therapy, oesophagectomy with peri-operative systemic treatment, neoadjuvant or definitive chemoradiotherapy, or symptom-focused care. Dysphagia palliation can involve systemic treatment, radiotherapy, endoscopic stenting or other techniques, but intervention should be selected alongside nutrition and anticipated survival because every option has burdens.
Key points
- NICE recommends a suspected-cancer pathway referral for dysphagia at any adult age; a trial of acid suppression must not postpone that referral.
- People aged 55 or over with weight loss plus upper abdominal pain, reflux or dyspepsia also meet the oesophageal or stomach cancer referral threshold.
- Progression from difficulty with solids to difficulty with liquids suggests mechanical narrowing, although advanced dysmotility and benign strictures remain important differentials.
- Upper-GI endoscopy defines the lesion and provides histology; biopsy technique and lesion description should support treatment planning rather than merely record a narrowed lumen.
- Squamous-cell carcinoma and adenocarcinoma differ in distribution, risk pattern and treatment options, so histological subtype and exact relationship to the gastro-oesophageal junction matter.
- Potentially curative disease is staged through an oesophago-gastric MDT using cross-sectional imaging, PET-CT and selective EUS or laparoscopy according to the clinical question.
- Malnutrition and sarcopenia are common at diagnosis; swallowing safety and dietetic intervention should begin during staging, not after a final treatment decision.
- Endoscopic resection can cure carefully staged superficial neoplasia, while more advanced local disease may require surgery, chemotherapy, chemoradiotherapy or a definitive non-operative strategy.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Reflux and Barrett pathway
Chronic reflux, Barrett metaplasia, central obesity and smoking increase distal oesophageal adenocarcinoma risk through metaplasia-dysplasia progression.
Squamous carcinogen exposure
Smoking and alcohol strongly increase squamous-cell carcinoma risk; cumulative exposure and nutritional or social factors often cluster.
Structural and host susceptibility
Increasing age, achalasia, prior caustic injury and selected inherited conditions increase risk, while many cancers arise without a known precursor.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Dysplastic epithelial transformation
Squamous mucosa or Barrett epithelium accumulates molecular alterations and progresses from dysplasia to invasive carcinoma through basement membrane.
- 2Circumferential and mural invasion
Tumour narrows the lumen and penetrates an oesophageal wall lacking a serosal barrier, causing progressive dysphagia and local extension.
- 3Early lymphatic dissemination
Longitudinal submucosal lymphatics permit regional nodal spread before a lesion appears bulky, with later liver, lung or other metastasis.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
New food sticking, prolonged mealtimes or avoidance of meat and bread may precede obvious liquid dysphagia. Ask where food seems to stick, but remember that perceived level does not reliably locate the lesion.
Unintentional weight loss, early satiety, reduced portions or reliance on liquids suggests both cancer risk and nutritional urgency. Record a measured weight trajectory rather than accepting a vague statement that appetite is poor.
Nocturnal regurgitation, coughing after swallowing, recurrent chest infection or a wet voice can reflect proximal pooling above an obstruction. Inability to manage saliva is an acute obstruction warning.
Haematemesis or melaena requires the acute upper-GI bleeding pathway. More often, chronic occult loss produces iron-deficiency anaemia, fatigue and exertional breathlessness that still require expedited investigation.
Hoarseness, persistent cough, focal bone pain, supraclavicular nodes, hepatomegaly or progressive back pain may indicate local invasion or metastasis and should be communicated on referral and staging requests.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Upper-GI endoscopy with biopsyFirst step - Why
- Visualise the obstruction, define its extent and obtain diagnostic histology.
- Interpretation and limitations
- Histology distinguishes adenocarcinoma, squamous carcinoma and benign or unusual lesions. A non-diagnostic superficial biopsy does not overrule a malignant appearance; repeat targeted sampling or an alternative tissue route should be agreed urgently.
- 02
Contrast CT chest and abdomen - Why
- Assess local relationships, nodes, distant spread and treatment feasibility.
- Interpretation and limitations
- CT may reveal invasion, liver or lung metastases and alternative causes of dysphagia. Radiological nodal size is imperfect; the MDT integrates CT with histology and further staging rather than declaring curability from CT alone.
- 03
FDG PET-CT - Why
- Search for metabolically active occult metastatic disease before radical treatment.
- Interpretation and limitations
- Use in potentially curable oesophageal or gastro-oesophageal junction cancer according to NICE and MDT selection. Inflammatory uptake and small-volume disease can mislead, so unexpected findings may need confirmation.
- 04
Endoscopic ultrasound - Why
- Refine tumour-wall and regional-node staging when it can change treatment.
- Interpretation and limitations
- EUS is most useful in selected potentially radical cases. A tight non-traversable tumour limits assessment; forcing the scope or routine dilatation solely for staging can create perforation risk.
- 05
Pathology and predictive markers - Why
- Confirm subtype and provide information needed for current oncology options.
- Interpretation and limitations
- The specialist pathology pathway records site and histology and requests treatment-relevant markers for advanced disease. Required panels evolve, so use the current regional oncology protocol rather than an old fixed list.
- 06
Fitness and nutritional assessment - Why
- Judge whether proposed radical treatment is tolerable and prevent avoidable depletion.
- Interpretation and limitations
- Review weight loss, swallowing safety, frailty, performance status, cardiopulmonary reserve, FBC, renal and liver profiles. Severe malnutrition can alter timing and route of treatment but should not cause unplanned diagnostic delay.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Peptic or eosinophilic stricture
Long reflux history or food impaction with benign biopsies may indicate inflammatory narrowing, but progressive alarm symptoms require adequate repeat sampling.
Achalasia
Liquids and solids affected from early on with a smooth taper and diagnostic manometry favours motor failure after pseudoachalasia is excluded.
Benign or functional dysphagia
Stable intermittent symptoms without weight loss may reflect rings or gut-brain disease, but dysphagia itself still warrants timely structural assessment.
Additional chapter-specific clues
Reflux stricture, eosinophilic oesophagitis, achalasia and motility disorders can resemble cancer. Their possibility is a reason for high-quality investigation, not for delaying the cancer pathway.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01ReferUse the cancer pathway promptlyFirst stepAn adult reports dysphagia, or a person aged 55 or over has weight loss with upper abdominal pain, reflux or dyspepsia.+
- 1Clarify progression, intake, weight, aspiration, bleeding and performance status, examine for metastatic signs, and submit a suspected-cancer referral using the applicable devolved-nation or local route.
- 2Safety-net immediate deterioration, particularly inability to swallow saliva, food-bolus obstruction, haematemesis or severe chest pain, because these features require acute assessment rather than waiting for an appointment.
- 3Do not substitute empirical PPI treatment, a normal plain radiograph or an old benign endoscopy for current investigation of a new qualifying symptom.
02StageDefine potentially curable diseaseEndoscopic biopsy confirms oesophageal or junctional malignancy without an obvious emergency complication.+
- 1Complete protocolled CT and review pathology in the specialist MDT, clarifying the epicentre and whether the lesion should follow an oesophageal, junctional or gastric treatment pathway.
- 2Add PET-CT for potentially curative oesophageal or junctional disease and use EUS or selective laparoscopy only when the information is likely to change a radical plan.
- 3Assess nutrition, frailty and cardiopulmonary fitness in parallel, then present genuine treatment choices with expected swallowing, recovery, recurrence and quality-of-life consequences.
03SupportRelieve dysphagia proportionatelyOral intake is unsafe or inadequate during staging, radical treatment or non-curative care.+
- 1Obtain specialist dietetic and swallowing input, choose texture and supplements safely, and discuss enteral access with the treating MDT because some routes can complicate future surgery.
- 2For non-curative obstruction, compare systemic therapy, radiotherapy, stenting and other endoscopic measures by speed of benefit, adverse effects, expected survival and the person's priorities.
- 3After any intervention, check pain, reflux, migration, aspiration, intake and re-obstruction, and provide a rapid contact route rather than assuming restored luminal diameter guarantees nutrition.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Obstruction and malnutrition
Progressive luminal narrowing limits solids then liquids, causing dehydration, sarcopenia and aspiration risk before staging and treatment are complete.
Airway fistula or aspiration
Local invasion can communicate with tracheobronchial structures, causing cough with swallowing, recurrent pneumonia and severe respiratory compromise.
Bleeding and metastatic disease
Tumour ulceration causes anaemia or haematemesis, while nodal and distant spread produces pain, cachexia and loss of curative options.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Track weight, oral intake, hydration, swallowing safety and functional status from referral through treatment, with early specialist dietetic review.
- Record completion and results of endoscopy, histology, CT and any indicated PET-CT or EUS so the MDT is not making decisions from an incomplete stage.
- During radical treatment, monitor regimen-specific haematological, renal, nutritional and cardiopulmonary toxicity through the oncology or surgical protocol.
- After endoscopic or surgical treatment, use the specialist surveillance plan and investigate new dysphagia rather than assuming it is postoperative scarring.
- In palliative care, review swallowing, secretion burden, pain, bleeding, aspiration and stent complications while aligning repeated procedures with goals of care.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Dysphagia stands alone
Unlike several age-and-symptom combinations in NG12, dysphagia itself is sufficient for suspected oesophageal cancer referral and should not be diluted by a low-risk profile.
Perceived level misleads
Patients may point to the neck even when food is held up distally, so anatomical localisation must come from investigation rather than symptom mapping.
Biopsy is not staging
Histological proof names the disease, while CT, PET-CT and selective local tests determine extent; neither part can substitute for the other.
Nutrition is active treatment
Maintaining intake can improve treatment delivery and recovery, but the access route should be planned with surgeons and oncologists so it does not compromise reconstruction.
A stent has trade-offs
Stents can restore swallowing quickly but may cause pain, reflux, migration or fistulation; slower alternatives may suit some people with a longer expected course.
11Common pitfallsFrequent interpretation and management errors.
- 01
Trying a PPI for several weeks before referring an adult with new dysphagia.
- 02
Assuming young age, absence of smoking or a normal examination excludes oesophageal cancer.
- 03
Forcing an endoscope or staging probe through a nearly occlusive lesion without a safe interventional plan.
- 04
Completing sequential staging tests while weight loss and aspiration remain unaddressed.
- 05
Treating a non-diagnostic biopsy as reassurance despite an endoscopically malignant stricture.
- 06
Choosing feeding access or a palliative stent before the oesophago-gastric MDT clarifies treatment intent.